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LIST  OF  CONTRIBUTORS 

TO   THIRD   VOLUME. 


BORCHARDT,  DR.  M. 
FRIEDRICH,  PROF.  DR.  P.  L. 
HOFFA,  PROF    DR.  A. 
HOFMEISTER,  PROF.  DR.  F. 
NASSE,  PROF.  DR.  D. 
REICHEL,  OBERARZT  DR.  P. 
SCHREIBER,  OBERARZT  DR.  A. 
WILMS,  PRIVAT-DOCENT  DR.  M. 


A  SYSTEM  OP 


PRACTICAL  SURGERY. 


BY 
Prof.  E.  von  BERGMANN,  M.D.,        Prof.  P.  von  BRUNS,  M.D., 

OF    BERLIN,  OF    TUBINGEN, 

AND 

Prof.  J.  von  MIKULICZ,  M.D., 

OF    BREST, AT'. 


VOLUME   III. 

TRANSLATED   AND    EDIT E D   B  Y 

WILLIAM   T.  BULL,  M.D., 

PROFESSOR    OF    SURGERY,   COLLEGE    OF    PHYSICIANS    AND    SURGEONS,   COLUMBIA    UNIVERSITY,  NEW  YORK, 


JOHN  B.  SOLLEY,  M.D., 

NEW    YORK. 


SURGERY  OF  THE  EXTREMITIES. 


LEA   BROTHERS   &   CO., 
NEW   YORK   AND   PHILADELPHIA. 

1904. 


Entered  according  to  Act  of  Congress,  in  the  year  1904,  by 

LEA   BROTHERS   &  CO., 

In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


WESTCOTT    &    THOMSON.  WILLIAM    J.     DORNAN, 

ELECTROTYPERS.    PHILADA.  PRINTER.    PHILADA. 


CONTENTS. 


MALFORMATIONS,    INJURIES,    AND    DISEASES    OF   THE 
SHOULDER  AND   UPPER  ARM. 

CHAPTER  I. 

PAGE 

Malformations  and  Injuries  of  the  Shoulder     .....        17 

CHAPTER  II. 

Diseases  of  the  Shoulder    .  .  .  .  .  .  .  .  .       78 

CHAPTER  III. 
Operations  on  the  Shoulder         ........      104 

CHAPTER  IV. 
Malformations  of  the  Upper  Arm         .  .  .  .  .  .  .117 

CHAPTER  V. 

Injuries  of  the  Upper  Arm  .  .  .  .  .  .  .  .  .118 

CHAPTER  VI. 
Diseases  of  the  Upper  Arm  ........      143 

CHAPTER  VII. 
Operations  on  the  Upper  Arm     .  .  .  .  .         .  .  .156 


MALFORMATIONS,    INJURIES,    AND    DISEASES    OF    THE 
ELBOW   AND    FOREARM. 

CHAPTER  VIII. 
Defects  of  the  Forearm  and  Malformations  of  the  Elbow-joint  .  .163 

CHAPTER  IX. 

Injuries  of  the  Elbow-joint         ........      166 

(v) 

362177 


vi  CONTENTS. 

CHAPTER  X. 

PAGE 

Diseases  of  the  Elbow-joint        ........     210 

CHAPTER  XI. 
Operations  on  the  Elbow-joint   ........     222 

CHAPTER  XII. 

Malformations,  Injuries,  and  Diseases  of  the  Skin  and  Soft  Parts  of 

the  Elbow  and  Forearm         ........     229 

CHAPTER  XIII. 
Malformations  of  the  Bones  of  the  Forearm     .....     243 

CHAPTER  XIV. 
Injuries  of  the  Bones  of  the  Forearm        ......     247 

CHAPTER  XV. 
Diseases  of  the  Bones  of  the  Forearm       ......     255 

CHAPTER   XVI. 
Operations  on  the  Elbow  and  Forearm       ......     259 

CHAPTER  XVII. 
Accident  and  Judgment         .........     263 


MALFORMATIONS,    INJURIES,    AND    DISEASES    OF   THE 
WRIST    AND    HAND. 

CHAPTER   XVIII. 
Malformations  of  the  Hand  Excepting  the  Congenital  Contractures     270 

CHAPTER  XIX. 
Injuries  of  the  Wrist  and  Hand  .  .  .  .  .  •  •     279 

CHAPTER  XX. 
Diseases  of  the  Wrist  and  Hand         .......     321 

CHAPTER  XXI. 
■  Operations  on  the  Wrist  and  Hand     .......     374 


CONTEXTS.  vii 

MALFORMATIONS,    INJURIES,    AND    DISEASES    OF    THE 
HIP  AND   THIGH. 

CHAPTER   XXII. 

PAGE 

Malformations  of  mi:  Hip-joint 389 

CHAPTER  XX1I1. 
Injuries  of  the  Hip      ..........     416 

CHAPTER  XXIV. 
Diseases  of  the  Hip     ..........     452 

CHAPTER  XXV. 
Operations  at  the  Hip.         .........     524 

CHAPTER  XXVI. 
Deformities  of  the  Thigh     .........     530 

CHAPTER  XXVII. 
Injuries  of  the  Thigh  .  .  .  .  .  .  .  .  .  ,     532 

CHAPTER  XXVIII. 
Diseases  of  the  Thigh  .........     549 

CHAPTER  XXIX. 
Operations  ox  the  Thigh 559 


INJURIES  AND  DISEASES  OF  THE  KNEE  AND  LEG. 

CHAPTER  XXX. 
Injuries  of  the  Knee  ..........     565 

CHAPTER  XXXI. 
Diseases  in  and  About  the  Kxee-joint        ......     594 

CHAPTER  XXXII. 
Malformations  of  the  Leg  .........     669 

CHAPTER  XXXIII. 
Injuries  of  the  Leg      ..........     671 


viii  CONTENTS. 

CHAPTER  XXXIV. 

PAGE 

Diseases  of  the  Leg     ..........     684 

CHAPTER  XXXV. 
Operations  on  the  Leg         .........     713 


MALFORMATIONS,    INJURIES,   AND    DISEASES    OF    THE 
ANKLE   AND   FOOT. 

CHAPTER   XXXVI. 

Congenital    Malformations    of    the    Foot    (Except    Congenital    Con- 
tractures)      ...........     722 

CHAPTER  XXXVII. 

Injuries  of  the  Ankle  and  Foot  .......     728 

CHAPTER  XXXVIII. 

Diseases  of  the  Ankle  and  Foot  .......      773 

CHAPTER  XXXIX. 
Operations  on  the  Foot  and  its  Joints        ......     873 


MALFORMATIONS.  INJURIES,  AND  DISEASES 
OF  THE  SHOULDER  AND  UPPER  ARM. 

By  Obekakzt  Dr.  A.  SCHREIBEB    \xd  Prof.  Dr.  F.  HOFMEISTER. 


CHAPTER   I. 

MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 
CONGENITAL  MALFORMATIONS. 

Congenital  Defects  of  the  Clavicle. — Congenital  defects  of  the 
cla\icle  are  rare,  and  are  observed  as  partial  or  complete  absence  of 
the  bone,  usually  bilateral  (Fig.  1). 
Sometimes  medial  rudiments  from  | 
to  2  inches  long  are  still  present,  the 
shoulder  being  usually  somewhat  de- 
pressed. In  the  majority  of  cases 
the  functional  disturbance  was  only 
slight,  so  that  the  malformation  was 
discovered  by  chance.  Adduction, 
which  is  usually  limited  by  the  action 
of  the  trapezius  and  levator  anguli 
scapula?,  could  be  increased  passively 
until  the  arms  met  upon  the  chest. 

Congenital  Elevation  of  the  Scap- 
ula (High  Shoulder).— Of  greater 
surgical  interest  is  the  congenital  high 
position  of  the  scapula.  Described 
first  by  Eulenberg  in  1863,  this  not 
infrequent  affection  received  general 
attention  only  after  Sprengel's  treatise 
(1891),  and  since  then,  under  the 
name  of  Sprengel's  deformity,  it  has 
been  the  subject  of  numerous  publi- 
cations, so  that  now  more  than  50 
cases  are  recorded.  The  deformity, 
discovered  usually  in  the  first  year, 
affects  the  male  with  greater  fre- 
quency (21  to  16).  Milo,  Honsell,  and 
Wittfield  described  cases  of  bilateral 

deformity.      Up   to  the  tenth  year  the        Congenital  absence  of  clavicle.   (Gross. 
Vol.  III.— 2  ( .17  ) 


18        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

amount  of  upward  displacement  of  the  scapula  varies  between  \  and 
2h  inches;  in  older  subjects  between  1  and  4\  inches.  Simultaneous 
rotation  of  the  scapula  has  been  seen,  the  lower  angle  approaching  the 
middle  line,  rarely  the  reverse.  In  individual  cases  the  upper  angle, 
bent  forward,  has  been  falsely  diagnosticated  as  an  exostosis.  Scoliosis 
of  varying  degree  is  a  frequent  accompaniment,  likewise  facial  asym- 
metry, rarely  other  deformities.  Functional  disturbance  was  generally 
absent;  in  some  cases  abduction  was  impaired.  Sprengel  and  most  of 
the  recent  writers  regard  this  elevation  of  the  scapula  as  a  deformity  of 
intra-uterine  origin  (the  result  of  insufficient  amniotic  fluid);  recently 
Kausch  demonstrated  defects  in  the  lower  part  of  the  trapezius  and 
regarded  them  as  responsible  for  the  deformity. 

As  to  the  treatment,  the  purely  orthopaedic  measures  have  been  thus 
far  without  notable  results.  Various  authors  claim  good  results  from 
division  of  the  elevators  of  the  scapula  combined  eventually  with  excision 
of  the  upper  angle  of  the  scapula.  As  a  rule  the  slight  functional  dis- 
turbance makes  treatment  unnecessary. 

Instances  of  acquired  high  position  of  the  shoulder  following  rhachitis 
have  been  described  by  Kolliker,  Gross,  and  Bender. 

Congenital  Dislocation  of  the  Shoulder.— Congenital  dislocation  has 
also  Keen  seen.  Smith  reports  subacromial  dislocation  of  the  clavicle. 
A  large  number  of  the  cases  described  as  congenital  dislocation  of 
the  shoulder  belong  among  the  deformities  of  paralysis;  still,  numerous 
positive  cases  have  been  described:  particularly  those  operated  upon 
cannot  be  doubted.  Phelps  saw  6  cases  and  operated  upon  4  of  them. 
Tilden  Brown  was  able  in  1  case  to  reduce  the  head  of  the  humerus 
after  incising  the  capsule.  Phelps,  in  the  majority  of  instances,  was 
obliged  to  remove  a  part  of  the  capsule  and  part  of  the  head.  Blood- 
less reduction,  subsequent  to  forcible  extension  and  followed  by  fixation 
for  several  months,  has  been  successful  in  a  few  instances. 

Dislocations  of  the  shoulder  (subcoracoid,  subacromial,  and  infra- 
spinate — the  latter  more  often  bilateral)  have  been  reported  by  R. 
Smith.  The  dislocation  was  usually  discovered  at  a  later  period  in 
childhood.  The  patients  frequently  showed  other  malformations  (club- 
foot, etc.).  In  most  of  the  cases  there  was  marked  atrophy  of  the 
muscles.  In  some  the  arm  could  only  be  swung  backward  and  forward, 
abduction  being  impossible.  The  pathological  specimens  showed  im- 
perfect development  of  the  articular  head  and  its  cavity,  the  latter  in 
some  cases  appearing  displaced  or  having  a  poorly  developed  margin. 
The  capsule  was  generally  normal,  the  head  of  the  humerus  somewhat 
oval,  the  tuberosity  separated  from  the  joint  surface  by  a  broad,  shallow 
groove,  that  is  to  say,  the  joint  surface  was  only  partially  developed. 
(R.  Smith.) 


INJURIES  OF  THE  skis  AND  MUSCLES  OF  THE  SHOULDER.     J9 


INJURIES  OF  THE  SKIN  AND  MUSCLES  OF  THE  SHOULDER. 

Avulsion  of  the  skin  of  the  shoulder  is  not  infrequent  as  a  result  of 
street  accidents  and  machinery  injuries,  and  was  formerly  much  dreaded 
on  account  of  the  subsequent  contractures.1  Especially  on  the  axillary 
borders,  if  large  skin  areas  are  involved,  surgeons  attempt  to  prevent 
contraction  by  transplanting  skin-flaps  from  the  chest  or  back.  Incised 
wounds  of  the  muscles  require  suture  as  a  rule  if  large. 

Subcutaneous  rupture  of  individual  muscles  is  observed  at  times. 
Rupture  of  the  deltoid  is  reported  by  Sedillot,  Arloing,  and  others,  and 
Regard  reports  that  of  \'S2  cases  of  rupture  14  were  of  the  deltoid. 
These  ruptures  occur  usually  in  lifting  heavy  bodies,  and  rarely  as  the 
result  of  direct  violence.  The  rupture  is  seldom  complete,  but  the  cleft 
in  the  substance  of  the  muscle  is  easily  recognized;  this,  together  with 
the  pain  and  the  appearance  of  ecchymosis  at  the  point  of  injury  (the 
latter  being  usually  about  two  inches  above  the  insertion  of  the  deltoid) 
makes  the  diagnosis  simple,  especially  when  an  attempt  to  abduct  the 
arm  widens  the  palpable  depression,  and  elevation  is  impossible.  Rup- 
tures of  the  rotators,  of  the  pectoralis,  etc.,  are  occasionally  seen,  but  are 
void  of  any  great  practical  importance.  Rupture  of  the  long  tendon  of 
the  biceps  will  be  described  later  under  ruptures  of  the  muscles  of 
its  group. 

Cases  of  so-called  dislocation  of  the  biceps  tendon  have  been  described 
by  Cooper,  Bromfield,  Duverney,  and  Monteggia,  which  are  open  to 
doubt  on  anatomical  grounds,  as  demonstrated  by  Schiiller,  and  by 
reason  of  the  easy  confusion  of  the  symptoms  as  given  with  those  of  a 
joint  sprain,  or  of  bursitis  subacromialis  or  subdeltoidea,  as  indicated 
by  Jarjavay. 

Tilmann  has  recently  called  attention  to  the  traumatic  lesions  of  the 
trapezius  and  the  importance  of  these  hitherto  disregarded  affections. 
They  result  from  pressure,  a  blow,  or  laceration  involving  the  muscle, 
and  often  lead  to  functional  disturbance  of  the  arm  that  may  last  for 
years.  As  an  important  subjective  symptom,  Tilmann  lays  stress  upon 
the  pains  which  radiate  into  the  arm  and  become  localized  in  the  region 
of  the  insertion  of  the  deltoid.  He  distinguishes  three  varieties  of  the 
affection:  1.  Impairment  of  the  entire  muscle,  the  scapula  being  rotated 
about  its  vertical  and  sagittal  axes,  the  shoulder  depressed  and  further 
from  the  middle  line,  the  inner  border  more  prominent  during  con- 
traction of  the  muscle,  and  the  action  of  the  trapezius  weak.  2.  Impair- 
ment of  the  lower,  adductor  portion,  characterized  by  limited  abduction, 
high  position  of  the  scapula,  and  increased  distance  from  the  middle 
line.  3.  Impairment  of  the  upper,  levator  portion,  recognizable  by  the 
depression  of  the  shoulder  and  rotation  of  the  lower  angle  toward  the 
middle  line;  movements  of  the  arm  free. 

1  The  term  contracture  is  used  in  conformity  with  the  later  nomenclature,  based  upon  the  path- 
ology- and  etiology  of  fixed  positions  of  joints — e.  g.,  cicatricial  contraction  of  the  skin  over  a 
joint  produces  a  contracture  of  the  joint. 


20       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


INJURIES  OF  THE  VESSELS  OF  THE  SHOULDER. 

Wounds  of  the  shoulder  are  particularly  dangerous  if  complicated  by 
injuries  of  the  large  vessels  of  the  neck  or  of  the  apex  of  the  lung  or 
pleura.  The  vessels  lying  under  the  clavicle  and  in  the  depth  of  the 
axilla  are  reached  easiest  by  penetrating  instruments.  In  gunshot- 
wounds  the  vessels  may  be  struck  by  the  projectile  itself  or  be  torn  by 
splinters  of  bone  or  sharp  fragments.  Complete  transverse  division  of 
a  vessel  by  the  projectile  is  rare;  more  frequently  the  vessel  is  opened 
laterally.  The  modern  metal-coated  bullets  with  their  enormous  pene- 
trating power  cut  like  a  knife  through  even  the  elastic  arterial  wall. 
The  bullet-wounds,  except  the  so-called  "  key-holers,"  are  so  small  that 
they  may  be  closed  by  the  pressure  of  the  adjacent  tissues.  MaeCormac 
saw  a  bullet-wound  of  the  axillary  artery  so  plugged  by  the  musculo- 
cutaneous nerve  that  no  bleeding  occurred;  it  began  only  on  retraction 
of  the  nerve,  and  necessitated  ligation. 

In  regard  to  the  frequency  of  wounds  of  the  vessels,  the  medical  report 
of  the  Franco-Prussian  War  gives  30  cases  of  ligation  of  the  subclavian 
(6  successful)  and  28  of  the  axillary  (13  successful).  In  the  War  of  the 
Rebellion  (in  878  cases  of  arterial  hemorrhage  in  the  upper  extremities) 
the  subclavian  was  ligated  51  times  (10  successfully),  the  axillary  49 
times  (with  a  mortality  of  85.7  per  cent.).  Simultaneous  injury  of  artery 
and  vein  is  not  rare.  In  13  punctured  wounds  Rotter  found  the  vein 
involved  5  times.  Kiittner  emphasizes  this  fact,  especially  with  reference 
to  the  modern  small-calibre  bullets.  Arteriovenous  aneurisms  have 
been  observed  repeatedly  in  the  region  of  the  axillary  vessels. 

Subcutaneous  injuries  of  the  large  branches  result  from  severe  crushing 
forces  which  affect  the  artery  directly;  from  violent  tearing,  if  the  arm 
is  jerked  backward  or  upward;  or  from  the  immediate  action  of  frag- 
ments upon  the  vessel-wall  in  fractures  of  the  upper  part  of  the  humerus 
or  clavicle.  Ziegler  saw  a  transverse  rupture  of  the  subclavian  due  to 
comminuted  fracture  of  the  scapula,  and  explained  it  by  overstretching, 
as  the  force  had  been  exerted  from  behind  forward,  and  the  fragments 
were  separated  from  the  vessel  by  a  thick  muscular  layer.  Vascular 
injuries  in  dislocation  of  the  shoulder  have  acquired  a  distinct  notoriety. 
Rupture  may  result  from  the  stretching  and  tearing  of  the  vessel,  pro- 
duced by  the  protruding  articular  head  at  the  moment  of  dislocation  or 
in  the  manipulation  of  reduction,  from  the  breaking  up  of  adhesions 
which  have  formed  between  the  vessel  and  dislocated  head.  Spicules 
of  bone  and  osteophytes  can  injure  the  vessel-wall,  as  is  illustrated  by 
the  cases  of  Anger,  Wutzer,  Gibson,  Roux,  and  others.  Also  splinters 
of  bone  from  fractures  complicating  the  dislocation  can  injure  the 
vessel. 

Korte,  who  collected  53  cases,  has  shown  that  in  about  one-fifth  of 
these  the  vessel  was  injured  at  the  time  of  dislocation,  more  frequently, 
however,  during  reduction.  Old  dislocations  present  the  greatest  con- 
tingent, a  fact  easy  to    understand  when  it    is  considered    how  much 


TNJUBIES  OF  TIH-:  VESSELS  OF  THE  SHOULDER.  21 

more  force  is  required  to  reduce  in  old  than  in  recent  cases,  and  the 
more  favorable  conditions  for  the  production  of  vascular  injury  given 
by  cicatrices,  adhesions,  and  new  hone  about  the  dislocated  head.  In 
considering  the  etiology  of  aneurisms  following  reduction  of  recent 
dislocations  it  must  always  be  remembered  thai  the  dislocated  head  can 
at  the  outset  close  the  hole  in  the  vessel,  the  blood  being  given  an  outlet 
for  the  first  time  at  the  moment  of  reposition.  Forcible  mobilization 
of  a  stiffened  shoulder-joint  may  injure  the  vessels,  particularly  if  inju- 
dicious abduction  is  employed. 

Paget  and  Korte  each  relate  a  case  in  which,  during  passive  motion 
to  overcome  a  contracture  of  the  shoulder-joint  following  inflammation, 
the  arm  was  suddenly  elevated  by  accident,  and  in  consequence  a  tear 
of  the  axillary  artery  resulted  which  led  to  the  formation  of  an  aneurism. 

The  lesions  produced  in  the  vessel  by  blunt  forces  differ;  most  fre- 
quently a  complete  transverse  rupture  is  seen,  rarely  round  or  oval  holes, 
which  in  certain  cases  without  doubt  indicate  avulsion  of  a  lateral 
branch  (subscapular  artery,  circumflex  humeri).  In  some  instances  the 
force  has  been  expended  before  producing  complete  separation;  the 
intima  and  media  are  torn,  but  the  adventitia  remains  intact.  The  torn 
inner  coats  curl  up  and  become  the  starting-point  of  a  more  or  less 
extensive  thrombosis.  Gangrene  of  the  finger  or  arm  may  result.  The 
process,  which  in  this  case  is  so  ominous  for  the  future  of  the  limb, 
is,  in  strong  contrast,  a  life-saving  agency  in  cases  of  severe  crushing  and 
laceration,  as  by  machinery  or  powder  explosions  (avulsion  of  arm). 
The  involution  of  the  intima  checks  the  primary  hemorrhage.  Arrest 
of  the  circulation  in  an  arterial  trunk  alone  is  not  sufficient,  however, 
to  produce  gangrene,  otherwise  it  would  be  impossible  to  explain  how 
ligation  of  the  subclavian  so  seldom  causes  gangrene  (3  out  of  90, 
v.  Bergmann),  and  indeed  is  able  to  check  a  beginning  gangrene.  Other 
factors  must  be  concerned.  Where  the  inner  coats  alone  are  ruptured, 
it  is  due  to  contusion  of  the  surrounding  parts  (Herzog) ;  in  cases  of 
complete  rupture,  as  also  in  puncture  and  shot-wounds,  where  the 
narrowness  and  shortness  of  the  wound  prevent  the  blood  from  escaping 
outward,  it  is  due  to  the  enlarging  hematoma  and  interstitial  infiltration. 
The  venous  channels  thus  become  compressed  and  the  development  of 
the  collateral  circulation  is  prevented.  Moreover,  v.  During  has  demon- 
strated that  resorption  of  fibrin-ferment  by  the  walls  of  the  small  veins 
favors  thrombosis  of  the  veins  still  unaffected. 

The  disturbances  of  innervation  which  follow  injuries  of  the  axillary 
vessels  appear  in  the  form  of  paresthesias  in  the  distal  portions  of  the 
limb,  more  or  less  severe  neuralgic  pains,  or  sensory  and  motor  disturb- 
ances. If  the  plexus  by  its  proximity  to  the  injured  vessel  shares  in  the 
damage  or  is  compressed  by  the  extravasated  blood,  the  pain  begins  at 
the  time  of  the  injury.  It  may  develop  gradually  with  the  growth  of 
the  hematoma,  in  which  case  it  usually  disappears  as  the  latter  is 
absorbed,  v.  Bramann  cites  3  cases  of  plexus  involvement  in  1G  cases 
of  injury  of  the  subclavian,  and  12  cases  in  29  of  injury  of  the  axillary 
artery. 


22        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

Except  for  their  effect  upon  the  nutrition  and  innervation  of  the 
extremity,  as  described,  the  injuries  of  the  large  axillary  vessels  have 
the  same  symptoms  and  sequelae  (primary  and  secondary  hemorrhage, 
formation  of  aneurisms,  suppuration  of  the  hsematoma)  as  those  of 
the  vessels  of  the  neck.  The  general  discussion  of  the  diagnosis  and 
prognosis  of  injuries  of  the  vessels  presented  by  Jordan  in  Vol.  II. 
applies  here.  A  special  point  is  that  hrematomata  and  diffuse  infiltra- 
tions of  blood  spread  by  predilection  in  the  direction  of  the  yielding 
axillary  space,  and  may  finally  perforate  beyond.  If  the  subcutaneous 
bleeding  continues  for  some  time,  the  infiltration  may  spread  over  wide 
areas  of  arm  and  thorax. 

As  to  the  prognosis,  the  available  statistics,  mostly  old,  present  a 
tragic  picture:  total  mortality  (Pirogoff),  68.1  per  cent.;  mortality  from 
secondary  hemorrhage  (Billroth),  81.2  per  cent.;  from  punctured 
wounds  (Thormann),  42.2  per  cent.;  from  gunshot-wounds  of  the 
shoulder  vessels  (Schmidt),  60  to  70  per  cent.  To-day  the  prognosis  of 
gunshot-injuries  in  particular  may  be  regarded  much  more  favorably, 
as  founded  upon  recent  war  experiences.  The  introduction  of  small- 
calibre  metal-coated  bullets  and  the  progress  made  in  treatment  have 
diminished  the  dangers  of  primary  hemorrhage  and  subsequent  septic 
hemorrhage.  The  percentage  of  resulting  aneurisms,  however,  has 
increased.  Injuries  of  the  vessels  associated  with  dislocation  of  the 
shoulder  give  an  unfavorable  prognosis.  Of  53  cases  related  by  Korte, 
34  died — of  these,  16  without  operation,  8  after  ligation  of  the  sub- 
clavian, 7  after  double  ligation  at  the  place  of  injury,  3  after  amputa- 
tion at  the  shoulder;  18  recovered — of  these,  6  without  operation,  8 
after  ligation  of  the  subclavian,  3  after  double  ligation  at  seat  of  injury, 
1  after  amputation  at  the  shoulder. 

The  general  principles  which  are  standard  for  wounds  of  the  arteries 
are  given  in  Vol.  II.  It  has  been  repeatedly  recommended  to  ligate  the 
subclavian  above  the  clavicle  previous  to  ligation  at  the  site  of  injury, 
as  the  latter  is  often  difficult  by  reason  of  the  extravasation  of  blood, 
or  at  least  to  pass  a  ligature  around  the  vessel  to  be  tied  in  case  of 
necessity,  as  digital  compression  in  the  supraclavicular  notch  has  often 
proved  uncertain,  particularly  if  hindered  by  thick  cushions  of  fat, 
enlarged  glands,  or  extravasation  of  blood.  It  is  better  still  to  make 
the  entire  trunk  accessible  by  a  longitudinal  incision,  temporary  resec- 
tion of  the  clavicle,  and  separation  of  the  fibres  of  the  pectoralis  major, 
as  employed  by  Langenbeck  and  recently  very  generally  approved.  If 
the  injury  involves  one  of  the  branches,  ligation  of  the  trunk  should 
be  avoided  if  possible.  In  a  case  of  avulsion  of  a  branch  (dislocation) 
Korte  recently  attempted  lateral  suture  of  the  vessel.  It  held  twenty- 
one  days,  but  ligation  of  the  axillary  was  necessitated  by  secondary 
hemorrhage. 

Large  or  rapidly  increasing  hsematomata  (in  subcutaneous  injuries  of 
the  arteries  or  with  obstruction  of  the  flow  toward  the  surface)  demand 
operative  interference:  first,  because  the  general  dangers  are  thereby 
most  quickly  avoided;  secondly,  because  the  relaxation  of  the  tissues  by 


INJURIES  OF  THE  NERVES  OF  THE  SHOULDER.  23 

removal  of  the  extravasation  improves  the  conditions  for  the  collateral 
circulation  and  the  venous  circulation,  and  thereby  prevents  most  effect- 
ually the  threatening  gangrene.  The  recognized  liability  of  tissues 
infiltrated  with  blood  to  septic  infection  seems  to  connterindicate  com- 
plete closure  of  wounds  after  such  evacuation.  Except  in  single 
instances  of  obstruction  due  to  rupture  of  the  inner  coats  of  the  artery, 
expectant  treatment  is  indicated  by  spontaneous  recovery  in  a  compara- 
tively large  percentage  of  eases.  Warmth  (Bryant)  and  moderate  ele- 
vation are  employed  to  increase  the  circulation,  their  continuance  being 
counterindicated  only  by  the  appearance  of  gangrene  or  by  associated 
injuries. 

INJURIES   OF  THE  AXILLARY  VEIN. 

Injuries  of  the  axillary  vein  are  much  less  frequent  than  those  of  the 
artery.  They  can  be  produced  by  the  same  causes  and  forces  that 
damage  the  arteries.  More  frequently  they  are  the  result  of  operative 
procedures  (removal  of  axillary  glands),  particularly  if  the  vein  is 
involved  in  the  mass  or  has  been  drawn  by  adhesions  toward  it,  so 
that  the  empty  vessel  is  not  recognized.  Not  infrequently  injury  of  the 
vein  is  unavoidable  and  necessitates  ligation  and  excision.  Contusion 
of  the  vein  by  blunt  forces  (fractures,  dislocations,  shot-injuries)  may 
produce  thrombosis,  although  this  is  less  frequent  here  than  in  the  veins 
of  the  lower  extremity. 

The  danger  of  venous  injuries  lies  not  only  in  the  bleeding,  but 
especially,  if  the  arm  is  lifted,  in  the  possibility  of  air  being  sucked 
into  the  open  subclavian.  Secondary  hemorrhage  and  pyaemia  are  also 
possible.  (In  regard  to  air-emboli,  see  Vol.  II.,  page  56;  on  page  59 
is  described  the  general  treatment  of  wounds  of  the  veins,  and  on  page 
60  the  injuries  and  ligation  of  the  subclavian.)  At  the  present  time 
ligation  of  the  axillary  vein  is  of  little  significance,  even  if  necessary 
above  the  junction  of  the  cephalic  vein.  The  slight  stasis  in  the  arm 
usually  disappears  spontaneously  or  after  bandaging  and  elevating. 


INJURIES  OF  THE  NERVES  OF    THE  SHOULDER. 

All  of  the  forces  causing  injuries  of  the  vessels  can  produce  lesions 
of  the  brachial  plexus.  Among  the  open  injuries  gunshot-wounds  are 
most  important. 

The  modern  metal-coated  bullets  rarely  produce  complete  transverse 
division  of  the  nerve-trunks.  They  graze  more  or  less  deeply  or  produce 
a  sort  of  button-hole  puncture.  Among  260  nerve  injuries  Fischer  gives 
53  of  the  brachial  plexus;  among  57  Beck  gives  15  of  the  brachial 
plexus,  and  among  16  Socin  gives  7  of  the  brachial  plexus.  In  the 
South-African  War  Kiittner  and  the  English  surgeons  found  that  the 
brachial  plexus  was  injured  with  remarkable  frequency;  it  is  explained 
by  the  prone  position  in  warfare. 


24        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

Among  the  injuries  due  to  blunt  forces  the  most  conspicuous  are  direct 
contusion  of  the  supraclavicular  region,  evulsion  of  the  arm  during 
delivery,  dislocation  of  the  humerus,  fracture  of  the  clavicle,  of  the  neck 
of  the  scapula,  and  of  the  humerus.  Associated  primary  injuries  of  the 
nerves  are  usually  the  effect  of  contusion.  Complete  transverse  division 
by  blunt  forces  is  extremely  rare.  Impalement  by  sharp  fragments  of 
bone  is  possible.  In  dislocation  of  the  shoulder  the  circumflex  nerve  is 
injured  more  frequently  than  the  main  trunks  of  the  plexus,  and  causes 
deltoid  paralysis. 

Long-continued  pressure  or  laceration  can  impair  or  destroy  the 
function  of  the  nerves  as  effectually  as  a  single  severe  contusion. 
Pressure  may  be  produced  by  lodged  foreign  bodies,  the  luxated  head 
of  the  humerus,  or  displaced  fragments  of  a  fracture. 

There  are  a  number  of  pressure-paralyses  of  the  brachial  plexus  which 
are  produced  in  part  by  "occupational  injuries,"  in  part  by  adventitious 
causes.  Among  them,  the  paralyses  due  to  strap-pressure,  seen  in 
peddlers,  etc.;  stone-carriers'  paralysis  of  Rieder;  so  also  "crutch  par- 
alysis," the  so-called  "sleep  paralysis"  (Saturday-night  paralysis),  and 
the  so-called  "narcosis  paralysis"  often  observed  after  a  protracted 
operation. 

Narcosis  paralysis,  which,  naturally,  is  not  due  to  the  anaesthetic,  is 
usually  discovered  on  awakening  from  the  anaesthesia.  It  varies  from 
slight  paresthesia  and  paresis  to  even  complete  sensory  and  motor 
paralysis  affecting  parts  of  or  the  entire  plexus.  The  sensory  area  of 
the  circumflex  nerve  is  found  unaffected  with  striking  frequency.  (Biklin- 
ger.)  The  paralysis  is  produced  most  often  by  elevation  of  the  arm 
accompanied  with  backward  depression  of  the  shoulder,  whereby  the 
plexus  is  compressed  between  the  clavicle  and  the  first  rib.  (Budinger, 
Gaupp.)  Braun  refers  it  to  pressure  of  the  head  of  the  humerus  upon 
the  nerves  of  the  axilla.  The  use  of  shoulder-supports  in  the  Tren- 
delenburg position  can  cause  brachial  paralysis. 

Secondary  traumatic  lesions  of  the  plexus  are  produced  by  the  pressure 
of  cicatrices  in  or  about  the  nerve,  by  the  pressure  of  excessive  callus 
against  or  around  the  nerve,  and  finally  by  an  apparently  infectious 
neuritis.  The  significance  of  arterial  hsematomata  in  regard  to  the 
plexus  has  already  been  mentioned. 

Symptoms. — The  symptoms  of  injuries  of  the  plexus  are  classified  as 
those  of  irritation  and  of  paralysis.  At  the  moment  of  injury  (for 
example,  in  shot-wounds)  a  sudden  excruciating,  "lightning-like"  pain 
is  often  described,  at  times  followed  by  general  shock.  Later,  pain  may 
be  absent  and  only  a  feeling  of  numbness  persist.  As  in  neuritis  or  as 
occasioned  by  the  above-mentioned  causes  (foreign  bodies,  cicatrices, 
etc.),  a  constant  irritation  may  persist  and  neuralgias  develop  which 
may  extend  over  wide  areas — in  fact,  radiate  into  the  unaffected  side 
of  the  body. 

Diagnosis. — For  the  diagnosis  the  paralyses  are  most  important.  For 
the  details  of  the  symptoms,  which  render  possible  the  accurate  locali- 
zation of  the  injury,  the  reader  is  referred  to  the  text-books  on  nervous 


l\.jl'j:/j:s  of  tin:  SERVES  OF  THE  SHOULDER.  25 

diseases.  Moreover,  the  primary  paralyses,  especially  in  shot-wounds, 
are  nol  necessarily  confined  to  the  nerve-trunk  immediately  concerned, 
as  Kiittner  has  recently  demonstrated.    He  found  total  paralysis  of  the 

plexus  in  cases  in  which  only  a  branch  had  been  affected — in  fait, 
where  the  nerve  had  not  been  touched — and  explained  it  as  the  tele- 
kinetic  action  of  penetrating  projectiles  of  high  velocity. 

Prognosis. — The  prognosis  of  these  plexus  paralyses  varies  with  the 
nature  of  the  lesion.  Complete  division  of  the  nerve  is  unfavorable,  as 
suture  of  the  plexus  does  not  give  the  results  obtained  in  the  more  distal 
nerve-trunks.  Of  (i  rases  of  complete  division  of  the  plexus  in  the  axilla 
with  suture,  in  only  1  was  the  use  of  the  hand  after  suture  as  good  as 
that  of  the  sound  one  (Etzold).  The  prognosis  of  modern  shot-wounds, 
in  which,  as  mentioned,  complete  division  is  rare,  does  not  appear  so 
unfavorable.  The  narcosis  paralyses  give  a  good  prospect  of  complete 
recovery,  even  if  a  long  period  elapses  before  motion  returns.  The 
latter  is  first  regained  usually  in  the  fingers  and  forearm.  The  prognosis 
of  the  "occupation"  pressure-paralyses  is  usually  also  good.  Ordinarily 
with  the  removal  of  the  existing  cause  motion  returns  quickly.  The 
paralysis  following  dislocation  of  the  shoulder  is  to  be  regarded  more 
unfavorably,  for,  although  recovery  follows  speedily  in  the  majority  of 
cases,  in  many  a  rapid  atrophy  takes  place  or  neuritis  develops  with 
violent  attacks  of  pain.  A  particularly  frequent  observation  is  that  of 
complete  deltoid  atrophy  with  lasting  impairment  of  motion.  In  many 
cases  mobility  returns  onlv  after  many  weeks  and  months  (in  a  case  of 
Duplay's,  after  six  months).  Neuromata  may  form  at  the  site  of  division 
of  the  plexus  as  a  result  of  cicatricial  adhesions.  Not  infrequently  severe 
neuralgias  occur  later,  also  trophic  disturbances.  The  prognosis  of 
secondary  nerve  lesions  is  always  doubtful.  It  depends  upon  whether 
the  cause  can  be  removed.  Kiittner  called  attention  to  the  possibility 
of  extensive  cicatricial  processes  developing  within  the  nerve-trunk 
following  gunshot-wounds  and  preventing  functional  repair. 

Treatment. — In  the  treatment  of  primary  paralysis  evidence  of  division 
of  the  nerve  is  conclusive.  Where  division  is  probable,  according  to 
the  nature  of  the  injury  (incised  and  punctured  wounds)  suture  of 
the  nerve  is  indicated;  where  not  probable,  expectant  treatment. 
This  applies  not  only  to  subcutaneous  injuries,  but  also  especially  to 
modern  gunshot-wounds,  as  the  nerve-trunks  are  not  severed  by  them. 
For  pressure-paralysis,  the  first  therapeutic  precept  is  removal  of  the 
cause.  As  the  causes  are  numerous  the  treatment  is  equally  varied: 
change  of  occupation,  reduction  of  dislocations  and  fractures,  operative 
removal  of  foreign  bodies  (bullets),  bone  splinters,  projecting  fragments, 
hsematomata,  resection  of  the  dislocated  head.  Nussbaum  relieved  a  case 
of  muscular  contracture  and  sensory  disturbance,  clue  to  a  blow  of  a 
musket,  by  stretching  the  nerves  at  the  elbow  and  in  the  axilla  and 
neck.  In  a  child  eleven  years  old  Vogt  freed  the  plexus  from  con- 
stricting callus  by  resecting  the  humerus. 

In  secondary  neuralgias  and  paralyses  the  decision  in  favor  of  opera- 
tive interference  is  made  more  quickly  than  in  primary  cases.     Here 


26        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

one  can  count  with  some  certainty  upon  an  object  for  surgical  attack 
— compressing  cicatrices,  callus — while,  on  the  other  hand,  from  the 
nature  of  these  changes  one  can  count  but  little  upon  spontaneous  cure. 
The  nerve  is  freed  from  the  cicatrix  or  callus  and  placed  in  the  healthiest 
tissues  possible.  It  may  be  necessary  to  resect  the  portion  of  nerve 
injured  by  the  cicatrix  and  to  suture.  Further,  massage,  electricity,  and 
exercise  should  be  employed  in  all  cases  whether  operation  is  necessary 
or  not. 

Various  surgical  procedures  have  been  suggested  to  improve  the 
function  in  incurable  paralyses  of  individual  muscles  of  the  shoulder. 
In  serratus  paralysis  Hecker  suggests  a  bandage  to  prevent  wing-like 
spreading  of  the  scapulae.  Gaupp  restored  the  normal  elevating  capa- 
bility of  the  arms  in  bilateral  paralysis  of  the  trapezius  (following  oper- 
ation for  cervical  glands  in  which  the  accessorious  was  cut)  by  a  sort  of 
jacket  which  drew  the  shoulders  backward.  In  a  case  of  progressive 
muscular  atrophy  affecting  chiefly  the  trapezii,  Eiselsberg  obtained 
a  good  result  by  suturing  together  the  scapulae  in  the  upper  half  and 
lengthening  the  clavicles. 


FRACTURES  OF  THE  CLAVICLE. 

Fractures  of  the  clavicle  are  among  the  most  frequent  bone  fractures, 
constituting  about  14  to  16  per  cent.  In  children  and  young  adults 
they  are  most  common  next  to  fractures  of  the  radius.  They  occur 
most  often  in  the  first  ten  years  of  life,  but  may  be  produced  in  utero 
or  during  delivery.  Gurlt,  Bruns,  and  English  statisticians  give  a  relative 
frequency  of  15  to  16  per  cent.,  Malgaigne  10  per  cent.,  Bardenheuer 
13  per  cent,  and  Pitha  18.7  per  cent.  In  children  the  fracture  occurs 
with  about  equal  frequency  in  both  sexes;  Kronlein  regards  it  as  the 
equivalent  of  shoulder  luxation  in  the  adult.  In  adults  it  is  more 
common  in  males  (4  to  1).     Bilateral  fractures  are  rare. 

Fig.  2. 


Infraction  of  the  clavicle,     (v.  Bruns.) 

One  distinguishes  between  fractures  complete  and  incomplete  (infrac- 
tion); single  or  multiple;  typical  inflexion  and  torsion  breaks;  and  in 
reference  to  the  seat,  fractures  of  the  acromial,  middle  and  sternal 
third,  and  of  the  epiphysis  and  shaft.  In  about  one-third  of  the 
cases  the  break  is  oblique  and  situated  at  the  junction  of  the  middle 
and  outer  third.  Fracture  of  the  inner  third  is  rare,  also  of  the  epiphysis. 
The  acromial  end  has  no  epiphysis. 


FRACTURES  OF  THE  CLAVICLE. 


27 


Etiology. — The  cause  is  usually  indirect  violence,  as  by  falling  upon 
the  hand  with  the  elbow  and  shoulder  fixed.  The  force  is  thus  trans- 
mitted to  the  clavicle,  which  is  forced  firmly  against  the  sternum;  its 
S  curve  is  increased  and  the  hone  breaks  at  the  weakest  point,  the 
junction  of  the  middle  and  outer  third.  It  may  he  due  to  muscular 
action,  as  in  raising  the  arm,  and  is  favored  by  pathological  processes. 
It  can  also  result  if  the  bone  is  depressed  so  that  the  first  rib  acts  as 
a  fulcrum,  or  by  forcible  compression  of  the  shoulders,  as  between  a 
wagon  and  a  wall,  etc.  By  direct  violence  the  break  may  occur  at 
any  point,  as  by  a  blow,  fall,  recoil  of  a  gun,  etc.,  but  is  usually  at  the 
exposed  outer  third. 

The  line  of  fracture  is  commonly  oblique,  agreeing  with  the  mechanism 
of  production.    Transverse  fractures  are  seen  in  children.    Double  and 

Fig.  3. 


Fracture  of  the  clavicle.     (Anger.) 


comminuted  fractures  by  direct  violence,  except  from  gunshot-wounds, 
are  rare.  Compound  fractures  are  exceptional  in  spite  of  the  super- 
ficial position  of  the  bone.  Complications  involving  the  adjacent  large 
vessels  and  nerve-trunks,  the  pleura,  and  lung  apices  are  equally  in- 
frequent. 

Symptoms  and  Diagnosis. — Fractures  of  the  middle  third  present  a 
characteristic  symptom-complex,  dominated  by  the  typical  dislocation 
resulting  from  the  combined  effect  of  muscular  traction  and  the  weight 
of  the  arm.  The  latter  depresses  the  shoulder  and  attached  outer 
fragment,  while  the  pectorals  draw  the  same  toward  the  middle  line  and 


28       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

forward.  The  proximal  fragment  is  drawn  upward  by  the  sternocleido- 
mastoid, so  the  outer  is  pushed  under  the  inner  fragment,  and  together 
they  form  an  upturned  angle.  At  times  the  displacement  is  so  marked 
that  the  fragments  form  a  T  or  Y.  The  shortening  by  displacement  is 
easily  verified  by  comparative  measurement  of  the  distance  between  the 
acromion  and  the  sternoclavicular  articulation  on  the  two  sides.  In 
transverse  fractures  the  displacement  is  usually  less  or  altogether  absent. 
The  same  applies  to  subperiosteal  fractures  and  infractions  in  childhood, 
where  often  little  if  any  irregularity  is  demonstrable.  With  marked  dis- 
placement the  outlines  of  the  inner  fragment  are  easily  palpable  through 
the  skin  and  often  visible.  By  grasping  the  two  fragments,  or  in  children, 
where  the  outer  fragment  is  small,  by  seizing  the  shoulder  firmly,  and 
moving  the  fragments  upon  each  other,  false  motion  and  crepitation 
are  usually  obtainable.  The  symptom-complex  is  complete  when  to 
this  direct  evidence  are  added  the  accessory  signs — e.  g.,  swelling 
and  ecchymosis  at  the  point  of  fracture,  the  inclination  of  the  head 

Fig.  4. 


Fracture  of  the  clavicle;  union  with  deformity,     (v.  Bruns.) 

toward  the  affected  side  to  relax  the  sternocleidomastoid,  and  finally 
the  inability  to  raise  the  arm.  The  latter  is  due  to  the  pain,  which 
may  be  overcome  by  irritating  the  fracture  surfaces.  The  diagnosis 
in  adults  is  thus  simple.  In  children  fracture  or  infraction  of  the  clavicle 
will  not  be  overlooked  if  the  rule  is  always  followed  to  ascertain  the 
condition  of  the  clavicle  whenever  a  child  complains  of  pain  in  the 
arm  and  will  not  move  it  voluntarily.  If  doubt  still  exists  after  the 
first  examination,  it  will  be  cleared  up  in  a  few  days  by  the  appearance 
of  a  circumscribed  spindle-shaped  swelling,  the  beginning  formation  of 
callus. 

In  fractures  of  the  outer  third  the  displacement  depends  upon  whether 
the  break  occurs  at  or  to  the  outer  side  of  the  coracoclavieular  ligament. 
Fractures  near  the  trapezoid  and  rhomboid  ligaments  cause  little  dis- 
placement. (R.  Smith.)  Fractures  beyond  this  usually  allow  the  inner 
end  of  the  outer  fragment  to  be  tilted  up  by  the  trapezius,  while  the 
inner  fragment  is  drawn  down  and  inward  by  the  muscles  attached 
to  its  under  surface.     Consequently  considerable  angular  displacement 


FRACTURES  OF  THE  CLAVICLE. 


29 


— in  fact,  to  a  right  angle — is  possible.  Fractures  near  the  acromial 
end  may  resemble  a  supra-acromial  dislocation;  but  the  localized  tender- 
ness, the  irregular  contour  of  the  surfaces,  the  crepitus,  and  accurate 
measurement  of  the  distance  from  the  edge  of  the  acromion  to  the 
projecting  edge  of  the  fracture — which  is  greater  than  the  width  of  the 
acromion — will  prevent  mistake.  In  the  infrequent  fractures  of  the 
inner  third,  displacement  is  usually  prevented  by  the  costoclavicular 
Ligament  below  and  the  sternocleidomastoid  muscle  above. 

Prognosis. — The  prognosis  of  fractures  of  the  clavicle  is  usually 
favorable.  Union  occurs  in  children  in  from  two  to  three  weeks,  in 
adults  in  from  three  to  five  weeks — an  average  of  twenty-eight  days 

Fig.  5. 


Modified  Velpeau  bandage. 

according  to  Gurlt;  and  even  a  persisting  deformity  usually  does  not 
essentially  impair  the  function  of  the  arm.  Only  union  with  marked 
displacement  can  cause  any  material  loss  of  function.  Pseudo- 
arthrosis is  rare  and  occurs  almost  exclusively  in  the  middle  third.  It 
does  not  seem  to  cause  any  impairment.  Callus  uniting  the  clavicle  to 
the  coracoid  process  or  to  the  rib  may  hinder  abduction  permanently. 
Pressure  of  the  callus  or  of  a  displaced  fragment  has  been  known  to 
produce  neuralgic  pains  and  even  paralysis  in  the  course  of  the  brachial 
plexus.  The  disability  due  to  functional  disturbances — atrophy  of  the 
muscles,  etc. — may  reach  a  high  grade,  10  to  50  per  cent.  Becker  saw 
a  case  weakened  50  per  cent,  in  working  ability  by  bilateral  fracture 
of  the  clavicle.     (See  chapter  on  Accidents  and  Judgments.) 


30        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

Treatment. — If  the  displacement  is  slight — as  in  infraction — a  simple 
sling  is  sufficient;  massage  hastens  union.  Dagron  reports  the  benefits 
of  massage  in  20  cases.  In  all  fractures  with  displacement  reduction  is 
indicated  at  the  outset.  This  is  effected  by  standing  behind  the  sitting 
patient  and — with  the  knee  against  the  back  if  necessary — drawing  the 
shoulder  forcibly  backward  and  upward.  Retention  is  more  difficult. 
The  splint  should  draw  the  shoulder  upward,  outward,  and  backward; 
to  this  end'  there  are  about  seventy  splints  (Gurlt)  of  varying  utility. 
Many  of  these,  useful  and  celebrated  in  their  time,  have  been  modified 


Fig.  6. 


Fracture  of  the  left  clavicle.     Modified  Sayre  dressing.     Towel  circular  of  upper  arm  held  by 
adhesive  plaster.     Adhesive-plaster  strap  ready.     (Scudder  on  Fractures.) 


and  replaced  by  others,  so  that  mention  only  is  necessary.  Petit's 
figure-of-eight  bandage  across  the  back,  drawing  the  shoulders  firmly 
backward,  accomplishes  by  force  what  Hippocrates'  method  effected 
by  gravity  in  the  dorsal  position  with  a  pad  between  the  shoulder- 
blades.  Desault's  and  Velpeau's  (Fig.  5)  dressings  are  historical.  To 
immobilize  the  upper  extremity  in  many  conditions — as  in  dislocations — 
they  are  both  effective.  But'  in  their  original  purpose,  fixation  of  the 
clavicular  fragments,  they  fail  entirely. 

In  emergency  the  towei  bandage  of  Szymanowski  is  useful.  A  three- 
cornered  cloth  is  laid  upon  the  sound  shoulder;  a  second  piece,  fastened 
about  the  upper  part  of  the  upper  a-m  of  the  affected  side,  draws  it 
backward;  a  third  piece    around   the   lower   part   of    the   upper  arm 


FRACTURES  OF  THE  CLA  VICLE. 


31 


draws    it    backward     and    upward,    and    a    fourth     about    the  elbow 
supports  it  and  the  forearm  over  the  chest. 

Sayre's  splint  should  be  classed  among  the  most  practical.  Even 
this  has  the  disadvantage  of  occasionally  producing  eczema,  ecehy- 
mosis,  and  abrasions,  particularly  in  obese  individuals  or  those  with 
delicate  skin,  and  of  leading  to  infection.  Individuals  who  perspire 
freely  have  sensitive  skin;  the  plaster  also  slips  easily.  To  obviate 
these   conditions,   elastic   bands    are    recommended,    as,    for   example, 


Fig.  7. 


Fig.  S. 


Fracture  of  the  left  clavicle.  First  ad- 
hesive-plaster strap  applied.  Shoulder 
carried  backward.  Fixed  point  established 
above  middle  of  humerus.  (Scudder  on 
Fractures. ) 


Fracture  of  the  left  clavicle.  First  adhesive- 
plaster  strap  applied.  Second  adhesive-plaster 
strap  being  applied.  Hole  in  plaster  for 
olecranon  visible.  Note  pad  for  wrist  and 
folded  towel  protecting  skin  of  arm  and  chest. 
(Scudder  on  Fractures.) 


Biingner's  three-ply  elastic  splint.  Of  complicated  apparatus,  the  one 
described  by  Heusner  (1895)  seems  most  practical.  (Fig.  12.)  From 
extensive  personal  experience  Schreiber  recommends  the  epaulette  splint 
of  Braatz  (Fig.  13),  which  follows  the  principle  of  the  Sayre  splint,  but 
purposes  to  avoid  its  objections.  The  elbow  of  the  injured  side  is  covered 
in  semiflexion  with  a  well-padded  plaster  sheath.  A  similar  covering  is 
placed  on  the  sound  shoulder — not  wide  enough  to  hinder  abduction. 
After  they  have  hardened,  the  arm  is  lifted  by  an  arm  strip  like  the  II 
strip  of  the  Sayre  splint  (Figs.  7  to  11),  and  another  strip  like  the  I 
of  the  Sayre  is  fastened  to  the  upper  third  of  the  arm  and  passed  across 
the  back  and  fastened  in  front.      A  third  strip  replaces  the  III  of  the 


32       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

Sayre.  The  whole  is  reinforced  by  a  few  turns  of  a  bandage.  Pro- 
jections may  be  moulded  in  plaster  upon  the  shoulder-cap  to  prevent  the 
bandages  from  slipping  sideways. 

The  best  results  are  obtained  by  Bardenheuer's  method  of  forcible 
traction,  valuable  for  marked  displacement,  and  particularly  indicated 
when  the  patient  is  recumbent  by  reason  of  other  injuries.  A  broad 
strip  of  adhesive  plaster  with  about  six  to  eight  pounds  attached 
draws  the  shoulder  and  upper  end  of  the  humerus  upward  and  back- 
ward.    The  forearm  is  fixed  in  the  Velpeau  position    with  adhesive 


Fig.  9. 


Fig.  10. 


Fracture  of  the  left  clavicle.  First 
and  second  adhesive-plaster  straps  ap- 
plied. Pad  in  left  hand.  Shoulder  pulled 
backward  and  elevated.  (Scudder  on 
Fractures. ) 


Fracture  of  the  right  clavicle.  Modified 
Sayre  dressing.  Posterior  view.  Shoulder 
elevated  and  pulled  backward.  Folded  towel 
seen  in  axilla  for  protection  to  skin.  (Scud- 
der on  Fractures. ) 


plaster  and  the  lower  end  of  the  humerus  pulled  downward  by  counter- 
extension  toward  the  other  side  of  the  bed.  A  firm  pad  is  laid  between 
the  shoulders  so  that  they  sink  backward.  The  pad  alone,  as  used 
by  Hippocrates,  suffices  for  cases  with  slight  displacement. 

Suture  of  the  bones  is  indicated  only  for  rebellious  fragments  and 
for  compound  fractures.  Dawson,  Langenbuch,  Bardenheuer,  Demons, 
and  Lejars  have  obtained  good  results  by  suturing;  Fevrier  has  col- 
lected 44  cases.  Other  authors  insist  that  even  after  suturing  the 
result   is  not  certain,  and   that   inc'sion  adds  to  the  dangers  of   the 


Fli.\("iri;i:s  of  THE  CLA  VWLE. 


33 


Fracture  of  the  clavicle  and  subluxation  of  the  acromioclavicular  joint.  Notice  elevation  of 
sin  miller  by  pressure  on  the  flexed  elbow  and  counterpressure  on  the  clavicle  by  a  bandage  and 
a  pad  (X)  placed  internal  to  the  acromioclavicular  joint.     (Scudder  on  Fractures.) 

I 

Fig.  12. 


Heusner's  apparatus  for  fracture  of  the  clavicle 


Vol.  III.— 3 


34       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

injury.  In  the  subjects — young  women — in  whom  we  desire  the  least 
deformity  the  scar  on  the  shoulder  is  most  objectionable.  Lejars  rec- 
ommends binding  two  pieces  of  stiff  wire  to  the  fragments.  Operative 
procedures  may  be  necessary  secondarily  if  a  projecting  fragment 
threatens  to  perforate  the  skin  or  if  a  hypertrophied  callus  by  pressure 
upon  the  brachial  plexus  causes  neuralgias  or  paralyses,  or  if  a  pseudo- 
arthrosis compromises  the  function  essentially. 

Fig.  13. 


Braatz  epaulette  dressing  for  fracture  of  the  clavicle. 

Gunshot-fractures  of  the  clavicle  derive  special  significance  from  asso- 
ciated injuries  of  the  nerves,  vessels,  ribs,  pleura,  or  lung.  The  latter 
are  decisive  for  the  mode  of  treatment.  Where  absent,  the  treatment 
differs  from  that  of  a  subcutaneous  fracture  only  in  the  application 
of  an  aseptic  dressing.  Complications  may  ensue  even  at  a  remote 
period  after  the  injury.  Fischer  saw  2  cases  of  empyema  requiring 
incision  following  gunshot-fracture  of  the  clavicle. 


DISLOCATIONS  OF  THE  CLAVICLE. 


The  strong  coracoclavicular  and  costoclavicular  ligaments  uniting  the 
clavicle  to  the  first  rib  and  to  the  scapula  readily  explain  the  infre- 
quency  of  dislocation — according  to  Gurlt,  4.S8  per  cent.  The  brittle 
clavicle  is  more  easily  fractured  than  dislocated.     Malgaigne,  Fischer, 


DISLOCATIONS  OF  THE  CLAVICLE. 


35 


and  others  regard  dislocation  of  the  acromial  end  as  more  frequent, 
which  corresponds  with  Schreiber's  experience,  in  that  he  has  seldom 
observed  the  sternal   luxation — less  frequently  than  is  stated  by  Pitha. 


Fig.  14. 


Coracoid  process. 
Coraeo-acromial 
ligament 
Long  tendon 
of  biceps. 
Glenoid  cavity. 


Outer  end  of 
clavicle. 


Deltoid. 
Infraspinatus. 
Old  supra-acromial  dislocation  of  clavicle. 


Dislocation  of  the  Acromial  End  of  the  Clavicle. 


Dislocation  of  the  acromial  end  of  the  clavicle  may  occur  upward 
or  downward,  and  may  be  complete  or  incomplete. 

Dislocation  Upward. — Dislocation  upward  (luxatio  supra-acromialis 
clavicularis  or  luxatio  scapula?  infraclavicularis)  occurs,  according  to 
Gurlt  and  Kronlein,  with  a  frequency  of  2.4  to  2.7  per  cent.;  Defran- 
ceschi  places  the  frequency  at  6  per  cent.  It  is  more  common  in  males 
of  advanced  age,  and  is  oftener  complete  than  incomplete. 

Etiology. — The  cause  is  almost  always  direct  violence  applied  to 
the  acromion  from  above  downward.  The  clavicle  is  pushed  downward, 
strikes  against  the  first  rib,  is  pushed  forward,  and  with  the  tearing 
of  the  acromioclavicular  ligament  the  outer  end  glides  upward  over 
the  acromion.  This  action  may  be  produced  by  a  blow,  by  a  heavy 
body  falling  from  above,  by  a  fall  upon  the  shoulder,  by  being  run 
over.  (Boudaille.)  The  acromion  is  drawn  downward  by  the  weight 
of  the  extremity,  according  to  the  extent  to  which  the  ligaments  are 
torn.  Consequently  rupture  of  the  acromioclavicular  ligament  alone 
permits  only  of  incomplete  luxation,  while  complete  luxation  presup- 
poses rupture  also  of  the  coracoclavicular  ligament. 

Symptoms. — The  pathognomonic  symptom  is  the  step-like  projection 
of  the  end  of  the  clavicle  (Fig.  15),  which  may  be  f,  f,  or  even  1  to 
It  inches  above  the  acromion,  according  to  the  extent  to  which  the 
ligaments  are  torn.  The  projection  moves  with  the  clavicle  and  can 
be  pushed  backward  and  forward.     In  complete  dislocation,  as  the 


36 


MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


clavicle  no  longer  acts  as  a  support,  the  shoulder  sinks  forward,  down- 
ward, and  inward.     Abduction  is  prevented  by  the  pain. 

Diagnosis. — The  diagnosis  of  complete  dislocation  is  easy  from  the 
symptoms  as  described.  Against  fracture  of  the  clavicle  are  the  equal 
length  of  the  two  clavicles,  the  absence  of  crepitus,  and  the  palpation 
of  the  deformity,  easily  effected  by  elevating  the  arm.  Confusion  with 
dislocation  of  the  shoulder  is  almost  out  of  question  if  the  exami- 
nation is  careful.  An  .r-ray  examination  may  deceive  in  two  ways: 
the  normal  space  between  the  acromion  and  clavicle — in  avray  pictures 


Fig.  15. 


Complete  supra-acromial  dislocation  of  the  clavicle.     (Stimson.) 


often  almost  a  finger's  breadth — may  be  mistaken  as  representing  dias- 
tasis, or  in  exposures  in  the  dorsal  position  the  shoulder  may  sink 
so  far  backward  that  in  spite  of  the  existence  of  dislocation  a  normal 
picture  is  obtained. 

Prognosis. — As  regards  complete  restoration  of  form,  the  prognosis 
is  not  favorable,  but  functional  impairment  is  slight  even  in  complete 
dislocation  with  marked  deformity.  In  general,  however,  the  functional 
disturbance  is  severe  in  proportion  to  the  deformity.  The  carrying 
of  heavy  burdens  is  particularly  difficult,  so  that  carpenters,  porters, 
masons,   etc.,   are   hindered   in    their   vocations.      Abduction   above   a 


DISLOCATIONS  OF  THE  OLA  VICLE.  37 

horizontal  may  be  prevented  permanently.  Schreiber  has  seen  a 
deforming  arthritis  develop  after  dislocation. 

Treatment. — Reduction  is  by  retraction  and  elevation  of  the  shoulder 
combined  with  direct  pressure  upon  the  acromial  end.  Retention  is 
difficult,  and  the  numerous  clavicular  splints  are  about  as  unsatisfactory 
as  Nielaton's  complicated  apparatus  with  pads  and  Laugier's  apparatus 
with  tourniquets.  Adhesive  plaster  makes  the  best  splint.  While  reduc- 
tion is  maintained  by  downward  pressure  upon  the  shoulder  and  upward 
pressure  upon  the  elbow  a  strip  of  adhesive  plaster  is  applied  over  the 
end  of  the  clavicle,  carried  firmly  down  the  posterior  surface  of  the 
arm,  around  under  the  padded  elbow,  up  the  inner  surface  of  the  arm, 
and  with  tension  over  the  shoulder  again  to  the  back.  A  few  turns 
of  bandage  are  made  around  the  upper  arm  to  fix  the  plaster  strip, 
and  the  forearm,  bent  sharply,  is  hung  in  a  sling. 

To  obviate  the  danger  of  decubitus,  Hofmeister  places  a  plaster-of- 
Paris  pad  about  6  inches  long  upon  the  shoulder,  over  which  the  adhe- 
sive strips  cross.  The  results  are  good.  In  place  of  the  adhesive  strips 
Leidy  Rhoads  recommends  a  leather  strap  and  buckle  to  lift  the  shoulder; 
it  may  be  tightened  as  desired. 

Bardenheuer  draws  the  arm  and  clavicle  downward  by  means  of 
an  adhesive  plaster  traction  splint  with  the  patient  in  the  dorsal  position. 
Another  strip  passes  over  a  pad  in  the  axilla  and  draws  the  scapula 
upward,  the  two  ends  crossing  over  the  clavicle.  For  ambulant  treat- 
ment he  recommends  his  spring-extension  splint — without  the  shoulder- 
brace  and  cap — shifting  it  forward  or  backward  according  to  the 
direction  of  the  dislocation. 

As  the  methods  mentioned  not  infrequently  fail,  fixation  by  suture 
has  been  tried.  Baum  draws  the  torn  ligaments  together  with  two 
subcutaneous  silk  ligatures,  reduces  the  dislocation,  and  ties  the  ends 
of  the  sutures  over  a  roll  of  adhesive  plaster,  analogous  to  Volkmann's 
patellar  ligature.  The  arm  is  supported  in  a  sling.  Helferich  and 
others  commend  this  method.  The  subcutaneous  suture  is  now  super- 
seded by  the  open  method  with  wire  sutures.  Its  use  in  recent  cases 
is  advocated  by  many.  Krecke  and  others  emphasize  the  importance 
of  not  depending  too  much  upon  the  probability  of  a  favorable  outcome, 
but  rather  of  trying  to  remove  completely  the  deformity  and  restore 
the  normal  function.  Suture  accomplishes  this  without  danger,  and 
should  be  applied  particularly  in  the  case  of  laborers,  who  require 
the  full  function  of  the  shoulder.  It  has  been  used  by  Paci,  Poirier, 
J.  Wolff,  and  others.  Krecke  obtained  primary  union  in  2  cases.  He 
does  not  use  drainage,  as  it  is  too  apt  to  be  followed  by  a  sinus,  which 
may  necessitate  removal  of  the  sutures.  In  such  sutured  cases  active 
motion  is  permitted  in  two  weeks,  thus  avoiding  any  great  muscular 
atrophy. 

Dislocation  Downward. — Subacromial  dislocation  (luxatio  subacromi- 
alis)  is  a  rare  injury.  Less  than  12  cases  are  recorded.  It  is  caused 
generally  by  a  blow  upon  the  upper  surface  of  the  clavicle  while  the 
arm  is  abducted,  the  force  driving  the  clavicle  downward.      It   may 


38        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

result  from  a  fall  upon  the  elbow  with  the  shoulder  fixed  or  encumbered, 
the  force  driving  the  acromion  upward. 

Symptoms. — The  symptoms  are  usually  distinct.  The  shoulder  is 
somewhat  depressed;  pain  is  felt  at  the  affeeted  spot  and  is  increased 
by  active  and  passive  motion.  The  hollows  above  and  below  the 
clavicle  are  effaced;  the  clavicle  recedes  rather  abruptly  from  its  middle 
point  toward  the  shoulder;  the  sternal  end  frequently  projects.  The 
acromial  end  is  absent  at  its  normal  position;  the  acromion  projects 
sharply,  so  that  the  joint  surfaces  may  be  felt  in  fresh  cases.  The 
acromion  appears  to  be  nearer  the  middle  line.  Formication  from 
pressure  upon  the  plexus  is  rare.  Functional  disturbance  is  marked. 
Abduction  especially  is  impaired. 

Diagnosis. — The  diagnosis,  on  account  of  the  concealed  position  of 
the  dislocated  end,  is  not  simple.  The  depression  of  the  outer  part  of 
the  clavicle  is  significant.  It  is  noticeable  even  with  much  swelling  if 
the  clavicle  is  palpated  from  its  inner  end,  the  finger  coming  abruptly 
against  the  facet  of  the  projecting  acromion.  The  head  of  the  humerus 
is  easily  recognized  in  its  normal  position. 

Prognosis. — The  prognosis  of  subacromial  dislocation  is  not  un- 
favorable, even  if  non-reduced.  Usually  no  important  functional 
disturbance  follows  and  a  serviceable  nearthrosis  forms,  muscles  and 
bones  adapting  themselves  to  the  new  position. 

Treatment. — Reduction  is  by  backward  traction  on  the  shoulder — or 
indirectly  by  pulling  outward  and  backward  on  the  abducted  arm — 
and  by  simultaneous  upward  pressure  upon  the  clavicle.  Retention 
is  by  means  of  an  axillary  pad  and  fixation  of  the  hand  upon  the  other 
shoulder.  Subcoracoid  dislocation  is  reduced  in  the  same  manner, 
but  may  require  more  force  and  some  assistance  to  disengage  the  end 
of  the  clavicle  from  beneath  the  coracoid  process. 

Subcoracoid  Dislocation. — Godemer  and  Pinjou  describe  a  more 
marked  form  of  downward  dislocation  (luxatio  subcoracoidea)  in  which 
the  outer  end  of  the  clavicle  is  supposed  to  be  dislocated  under  the 
coracoid  process.  Naturally  it  is  only  possible  after  rupture  of  all  the 
ligaments — acromioclavicular  and  coracoclavicular.  About  6  cases  are 
reported.  The  authenticity  of  some  cases  is  doubted  (Hamilton). 
Terrier  and  Ginestone  observed  this  form  combined  with  dislocation  of  the 
shoulder.  The  symptoms  are  striking  prominence  of  the  acromion  and 
coracoid  process  and  a  deep  depression  at  the  outer  end  of  the  clavicle. 
The  end  of  the  bone  may  rest  against  the  head  of  the  humerus  or  be  felt  in 
the  axilla. 

Dislocations  of  the  Sternal  End  of  the  Clavicle. 

The  sternoclavicular  joint  is  divided  by  a  meniscus  into  two  parts. 
Dislocation  may  occur  proximal  or  distal  to  the  ligamentous  disk. 
Dislocation  of  the  sternal  end  is  possible  in  three  directions: 

(a)  Forward,  luxatio  prsesternalis. 

(6)  Upward,  luxatio  suprasternal. 

(c)  Backward,  luxatio  retrosternalis. 


DISLOCATIONS  OF  THE  CLAVICLE.  39 

Dislocation  Forward.  Of  the  three  forms,  this  is  the  most  frequenl 
and  represents  about  1.5  per  cent,  of  all  dislocations.  It  occurs  chiefly 
during  middle  age  and  in  men,  and  is  more  frequently  complete  than 
incomplete. 

Etiology. — The  cause  is  excessive  backward  motion  of  the  shoulder 
from  a  blow,  a  fall,  run-over  accident,  machinery  accident,  etc.;  also 
the  sudden  slipping  from  the  shoulder  of  a  strap  used  in  carrying  burdens. 
Less  often  it  results  from  muscular  traction  as  in  hurling  heavy  objects, 
gymnastic  and  military  exercises,  etc.  It  is  seen  occasionally  as  a 
complication  of  fracture  of  the  acromion,  of  the  coracoid  process,  or 
of  the  upper  ribs.  Stetter  believes  the  presternal  position  is  secondary 
to  the  suprasternal  dislocation,  and  is  the  result  of  a  force  exerted 
from  in  front  striking  the  depressed  shoulder  and  driving  the  sternal 
end  against  and  through  the  upper  capsule,  and  that  it  is  more  frequent 
than  the  fulcrum  action  of  the  first  rib,  described  by  Hiiter,  when 
the  acromion  is  pressed  forcibly  downward. 

Symptoms. — The  symptoms  are  continuous  pain  in  the  joint,  inclina- 
tion of  the  head  toward  the  affected  side,  and  depressed  shoulder. 
The  dislocated  head  projects  forward,  especially  in  recent  and  old 
cases,  a  projection  made  more  distinct  by  motion.  The  line  of  the 
clavicle  is  less  prominent.  At  the  joint  a  depression  is  palpable.  The 
distance  from  the  sternum  to  the  acromial  end  and  to  the  midpoint  of 
the  incisura  jugularis  are  shortened.  Sometimes  pressure  upon  the 
nerves  causes  numbness  and  tingling  in  the  arm.  Often  the  function 
of  the  arm  is  impaired  so  slightly  that  the  patient  considers  medical 
aid  unnecessary. 

Diagnosis. — The  diagnosis  is  rendered  difficult  only  by  a  thick 
panniculus  or  extravasation  and  by  complications.  In  fractures  near 
the  joint  crepitus  is   usually   obtainable. 

Prognosis. — The  prognosis  is  generally  favorable.  Even  with  incom- 
plete reduction  full  use  of  the  arm  returns.  In  certain  cases,  however, 
the  functional  disturbances  may  be  more  severe.  The  deformity  is 
rarely  reduced  completely — that  is,  an  incomplete  dislocation  persists. 

Treatment. — Reduction  is  by  backward  and  outward  traction  upon 
the  shoulder  and  pressure  upon  the  sternal  end  of  the  clavicle.  Reten- 
tion is  rarely  successful  regardless  of  the  splint  or  apparatus  used.  Konig 
recommends  rubber  plates  fastened  down  by  adhesive  strips.  Barden- 
heuer  advocates  forcible  traction,  as  for  fractured  clavicle,  combined 
with  the  pressure  of  a  pad;  or  Malgaigne's  hook;  or  his  spring-traction 
splint.  [Stimson  advises  a  figure-of-eight  adhesive- plaster  splint  crossing 
in  front  with  pad  or  moulded  plaster,  and  for  severe  cases  the  dorsal 
position  with  appropriate  pressure — even  digital  if  necessary.  He  has 
obtained  good  results  from  the  periarticular  injection  of  alcohol.  The 
various  operative  procedures  recommended  by  Konig  (suture  of  the 
capsule),  Gersuny  (transplantation  of  the  sternocleidomastoid),  and 
others  are  not  widely  employed  in  America.] 

Dislocation  Upward. — Luxatio  suprasternal  is  much  less  frequent. 
About  20  cases  are  recorded.     In  this  accident  the  end  of  the  bone  is 


40        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

forced  through  the  upper  part  of  the  capsule,  the  costoclavicular  and 
sternoclavicular  ligaments  are  ruptured,  and  the  head  passes  further 
between  the  sternomastoid  and  sternohyoid  muscles  even  into  the  neck, 
and  has  been  pushed  even  up  to  the  larynx.  The  cause  is  forcible 
depression  of  the  shoulder  downward  and  backward;  or  leverage  upon 
the  first  rib  from  direct  violence  upon  the  depressed  shoulder;  also 
a  fall,  etc.  A.  X.  Blodgett  reports  the  case  of  a  man  carrying  one 
end  of  a  piano,  in  which  the  sudden  dropping  of  the  other  end  pro- 
duced an  upward  and  inward  dislocation  of  the  clavicle  and  a  forward 
and  outward  dislocation  of  the  first  and  second  costal  cartilages. 

Symptoms  and  Diagnosis. — The  symptoms  are  protrusion  of  the  end 
of  the  bone  in  the  neck,  flattening  of  the  shoulder  downward  and  inward, 
obliquity  of  the  clavicle,  shallowness  of  the  infraclavicular  and  supra- 
clavicular depressions;  less  frequently  severe  pain  and  aphasia  or 
dyspnoea  from  pressure  upon  the  larynx. 

Treatment. — Reduction  is  by  outward  traction  upon  the  shoulder 
and  direct  pressure  downward  upon  the  end  of  the  bone.  Retention  is 
seldom  complete.  Bardenheuer  recommended  continuous  traction  upon 
the  arm.  Dorsal  position  and  fixation  of  the  shoulder  have  given 
fairly  good  results.  Andrews  advises  a  figure-of-eight  bandage  with  a 
pressure-pad  and  fixation  of  the  head  inclined  slightly  forward  and 
rotated  to  relax  the  sternomastoid.  [The  operative  procedures  of  sutur- 
ing and  fixing  with  bone  pins  have  few  advocates  in  America.] 

Dislocation  Backward.— Luxatio  retrosternalis  is  rare  [second  in 
frequencv,  Stimson].  Malgaigne  collected  11  cases  [Stimson  gives  only 
2  cases  as  coming  under  direct  examination].  The  dislocation  may  be 
complete  or  incomplete.  In  the  former  the  degree  of  displacement 
differs  greatly,  a  fact  which  has  led  to  subdivision  by  many  authors. 

Etiology. — The  cause  is  direct  violence  from  the  front  pushing  the 
end  of  the  bone  through  the  capsule,  or  indirect  violence,  by  which, 
the  shoulder  being  pushed  forward  from  behind,  the  force  is  transmitted 
through  the  rigid  clavicle  in  the  opposite  direction,  that  is,  backward. 
In  complete  dislocation  the  capsule  is  torn  entirely,  the  interarticular 
cartilage  remaining  attached  to  the  sternum.  The  head  of  the  clavicle 
is  dislocated  backward  and  may  press  upon  the  carotid  or  jugular,  the 
subclavian  artery  and  vein,  or  upon  the  phrenic  nerve  or  vagus.  In 
the  same  way  the  oesophagus  or  trachea  may  be  compressed.  Schreiber 
saw  a  case  in  which  the  trachea  was  ruptured. 

Symptoms  and  Diagnosis. — The  most  striking  symptom  is  the  absence 
of  the  head  of  the  clavicle  at  its  normal  position,  in  place  of  which  a 
distinct  pit  is  palpable.  The  head  is  felt  more  or  less  deeply  in  the 
neck  behind  the  sternum  as  a  hard  rounded  body  which  moves  with 
the  shoulder.  The  supraclavicular  and  infraclavicular  depressions  are 
shallower.  The  sternomastoid  is  more  prominent  on  the  unaffected 
side.  The  shoulder  projects  forward  somewhat.  The  head  pressing 
upon  the  structures  behind  may  produce  circulatory  disturbances  in 
the  arm — absence  of  radial  pulse;  and  in  the  head — syncope,  tinnitus. 
There  may  be  dysphagia,  singultus,  and  dyspnoea  even   to  absolute 


FRACTURES  OF  THE  SCAPULA.  41 

asphyxia.      In   Schreiber's   ease   a    cutaneous   emphysema    developed 

rapidly,  and  completely  concealed  the  deformity.  Except  for  the  rare 
complication  of  emphysema  or  marked  traumatic  swelling  about  the 
joint  the  diagnosis  is  simple. 

Prognosis. — The  prognosis  is  not  unfavorable,  as  usually  the  func- 
tion of  the  pails  is  regained  even  if  retention  is  incomplete.  Compli- 
cations may  be  serious — for  example,  a  case  of  rupture  of  the  trachea 
was  fatal  from  empyema.  Usually  the  tissues  adapt  themselves  to  the 
pressure,  so  that  the  troublesome  symptoms  disappear  spontaneously. 

Treatment. — Reduction  is  by  strong  traction  backward  and  outward 
Upon  both  shoulders,  with  the  knee  between  the  shoulder-blades  if 
necessary;  the  impulse  forces  the  head  of  the  bone  forward.  In  the 
presence  of  threatening  symptoms  one  might  draw  the  head  forward 
with  a  blunt  hook  (a  questionable  procedure).  The  method  of  retention 
is  the  same  as  for  forward  dislocation.  The  shoulder  should  be  held 
back  firmly  and  the  dressing  examined  frequently  to  prevent  recurrence. 

Total  Dislocation  of  the  Clavicle. 

Dislocation  of  the  clavicle  at  both  ends  is  very  rare.  Lucas  collected 
10  cases,  all  occurring  between  the  ages  of  thirteen  and  thirty-nine. 
In  younger  subjects  fracture  is  more  apt  to  occur.  Of  Kaufmann's  8 
cases,  7  were  in  males,  of  which  6  were  adults.  They  resulted  from  force 
from  behind  pressing  the  shoulders  together  in  such  a  way  that  wdiile 
one  shoulder  was  fixed  the  body  was  rotated  about  it;  as  in  run-over 
accidents,  car-buffer  accidents,  fall  from  a  height,  from  driver's  seat,  etc. 
Parral  regards  unusual  solidity  of  the  clavicle  as  the  common  predis- 
posing cause. 

Symptoms. — The  symptoms  are  those  of  sternal  and  acromial  dis- 
location combined.  The  entire  clavicle  is  abnormally  movable  and 
yields  to  upward  and  downward  pressure.  It  may  be  rotated  easily 
on  its  mid-axis. 

Prognosis. — The  prognosis  is  not  unfavorable.  In  none  of  the  cases 
was  there  any  permanent  loss,  and  as  a  rule  the  functional  result  was 
good. 

Treatment. — Reduction  is  usually  easy  by  backward  traction  upon 
the  shoulder  combined  with  pressure  upon  the  sternal  end  of  the  clavicle. 
Retention  is  difficult.  In  Kaufmann's  case  presternal  dislocation 
persisted. 

Pathological  dislocations  have  been  seen  associated  with  spinal  curva- 
tures, bone  and  joint  diseases.  Cooper  was  compelled  to  resect  the 
head  in  a  case  of  posterior  dislocation  following  scoliosis. 

FRACTURES  OF  THE   SCAPULA. 

Fractures  of  the  scapula  are  comparatively  rare — about  1  per  cent, 
of  all  fractures.    Bruns  gives  0.86  per  cent.,  Richter  4  per  cent.    They 


42        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

occur  most  frequently  in  males  between  the  ages  of  twenty-one  and 
fifty  years,  rarely  in  women,  even  more  so  in  children.  We  dis- 
tinguish: 1.  Fractures  of  the  body  and  of  the  angle  of  the  scapula. 
2.  Fractures  of  the  glenoid  cavity.  3.  Fractures  of  the  neck.  4.  Frac- 
tures of  the  acromion  and  of  the  spine.  5.  Fractures  of  the  coracoid 
process.  In  order  of  frequency  Ricard  gives  fractures  of  the  body,  of 
the  neck,  of  the  acromion. 

Fracture  of  the  Body  of  the  Scapula. — Fractures  of  the  body  occur 
as  fissures,  without  essential  displacement;  as  complete  fractures,  either 
longitudinal,  transverse,  stellate,  or  comminuted.  Transverse  fractures 
are  most  commonly  situated  below  the  spine  in  the  infraspinate  fossa, 
and  are  sometimes  double.  They  result  from  direct  violence,  as 
from  street  accidents,  blows  upon  the  shoulder,  or  the  impact  of 
heavy  bodies,  as  in  quarries  from  blasting,  and  are  therefore  accom- 
panied by  severe  contusion  of  the  soft  parts,  which  often  leads  to  the 
formation  of  a  fluctuating  hematoma.  Compound  fractures  are  rare 
on  account  of  the  thick  padding  formed  by  the  soft  parts.  Single  frag- 
ments when  free  are  usually  displaced  by  the  traction  of  attached 
muscles — for  example,  in  a  transverse  fracture  of  the  lower  scapular 
angle  the  lower  fragment  will  be  drawn  upward,  forward,  and  out- 
ward by  the  serratus  magnus  and  teres  major.  In  fractures  of  the 
upper  angle  the  latter  will  be  drawn  upward  and  inward  by  the  levator 
angulse  scapulae. 

Symptoms  and  Diagnosis. — The  important  symptoms  are  localized 
pain,  abnormal  mobility  of  the  parts,  changes  in  the  contour  of  the 
scapula,  and  crepitus.  They  may  be  marked  or  slight.  Especially  the 
incomplete  and  longitudinal  fractures  may  escape  diagnosis.  The  dis- 
placement is  most  easily  detected,  according  to  HofYa,  by  drawing  the 
arm  behind  the  back,  thus  bringing  out  the  wing  shape  of  the  scapula. 

Prognosis. — The  prognosis  of  fractures  of  the  body  of  the  scapula, 
disregarding  complications,  is  favorable,  as  recovery  is  good  even  if 
the  fragments  cannot  be  accurately  apposed.  The  occasional  irregu- 
larity in  form  affects  the  function  of  the  scapula  but  little.  Exostoses 
or  inflammatory  processes  in  the  bursa  subserrata  may  produce  perma- 
nent disability — e.  g.,  for  porters,  etc. 

Treatment.— The  treatment  consists  in  fixing  the  arm  upon  the  chest 
in  the  position  most  effectually  approximating  the  fragments.  The 
Velpeau  position  is  usually  the  best.  Gurlt  recommends  a  shield  of 
long  adhesive  strips;  Konig,  suture  of  the  bone.  [Operative  interference 
is  not  advisable  as  a  rule  for  simple  fractures.  For  compound  fractures 
of  the  body,  Stimson  emphasizes  the  necessity,  in  addition  to  the  usual 
procedure  for  open  wounds,  of  removing  any  fragments  of  bone  which 
are  liable  to  prevent  free  drainage  and  lead  to  burrowing  of  pus  upon 
the  costal  surface  of  the  bone,  a  possibility  peculiar  to  the  region.  He 
notes  that  simple  cases  have  become  purulent,  apparently  from  im- 
perfect immobilization,  the  pus  burrowing  downward.] 

Fracture  of  the  Angles.— Isolated  fractures  of  the  upper  and  lower 
angle  of  the  scapula  have  been  seen,  usually  from  direct  violence— ?.  g.y 


FRACTURES  OF  THE  SCAPULA. 


43 


from  a  blow,  a  push,  falling  backward  upon  stairs,  etc.  They  occur 
rarely  from  muscular  traction.  Guinard  saw  such  in  a  hoy  who  tried 
to  free  himself  from  beneath  his  opponent  in  wrestling.  The  separation 
of  the  lower  angle  is  usually  more  or  less  transverse,  often  with  fissures 
in  the  body  of  the  scapula.  Displacement  i>  generally  marked.  In  a 
case  of  Sabatier's  the  fragment  was  so  sharp  that  it  threatened  to  per- 
forate the  skin. 

Fracture  of  the  Glenoid  Portion.— Fracture  of  the  articular  portion 
of  the  scapula  not  only  occurs  as  a  "chipping  off"  of  parts  of  the  rim 
in  connection  with  dislocation  of  the  shoulder  (Fig.  16),  hut  especially 
as  an  avulsion  of  the  entire  articular  portion — fractura  colli  anatomica. 
Gurlt,  Spencer,  and  Volkmann  have  seen  this  rare  injury.  It  is  usu- 
ally the  result  of  a  fall  upon  the  shoulder,  and  of  hyperahduction  if 
the  ligaments  are  less  yielding  than  the  bone. 


Fig.  16. 


Fig.  17. 


Fig.  16. — Incomplete  longitudinal  fracture  of  the  glenoid  cavity,     (v.  Bruns.) 
Fin.  17. — Fracture  •partial  i   of  the  neck  of   the  scapula,     b.  Upper  line  of  the  glenoid  cavity. 
d.  Intact  portion  of  the  glenoid  cavity,     e.  Lower  fragment,     (v.  Bruns.) 


The  symptoms  will  be  found  given  under  the  description  of  the 
fractura  colli  chirurgici,  from  which  the  symptoms  of  fracture  of  the 
anatomical  neck  differ  only  in  that  the  coracoid  process  is  in  its  normal 
position  and  does  not  follow  the  movements  of  the  arm.  Chipping  of 
the  glenoid  margin  is  recognizable  with  certainty  only  when,  secondary 
to  the  symptoms  of  joint  contusion,  bony  crepitus  is  obtainable  or  the 
.r-ray  shows  the  condition. 

Fracture  of  the  Surgical  Neck. — Of  greater  practical  importance  is 
fracture  of  the  surgical  neck,  in  which  the  articular  portion  breaks  off 
simultaneously  with  the  coracoid  process,  so  that  the  line  of  fracture, 
according  to  Lotzbeck,  runs  downward  from  the  incisura  scapula?. 
Among  1901  fractures  seen  by  Lonsdale  in  the  Middlesex  Hospital 
there  were  18  of  the  scapula  and  2  of  the  neck;  Lente  saw  17  of  the 
scapula  and  1  of  the  neck  in  1722  cases;  Weber  3  of  the  neck  among 
16  of  the  scapula;  Lotzbeck  2  among  12.  The  cause  is  usually  direct 
violence — a  blow,  a  push,  street  accidents,  fall  from  a  wagon,  fall 
upon  the  stairs,  fall  from  a  horse,  rarely  by  muscular  action — e.g., 
in  throwing  a  scarf   over  the  head  as  cited  by  G.  May. 


44:        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

Symptoms  and  Diagnosis. — The  symptoms  are  flattening  of  the 
shoulder,  prominence  of  the  acromion,  as  a  rule  lengthening  of  the 
arm — 1  to  2  inches.  Often  the  head  of  the  humerus  cannot  be  felt 
in  the  axilla,  but  instead  one  feels  the  sharp,  irregular  edge  of  the 
fracture,  manipulation  of  which  is  painful.  The  arm  is  abducted  and 
is  not  in  the  axis  of  the  shoulder-joint,  so  that  it  resembles  a  dislocation. 
The  lowered  position  of  the  coracoid  process  is  recognizable  at  times. 
Usually  it  is  readily  seen  that  it  follows  the  movements  of  the  arm. 
The  diagnosis  is  essentially  a  differential  one  from  dislocation  of  the 
humerus.  The  free  mobility  and  easy  reducibility  of  the  deformity 
are  conclusive.  On  elevating  the  arm  and  making  pressure  in  the 
axilla  the  deformity  disappears,  to  return  as  soon  as  the  arm  is 
released.  Distinct  crepitus  is  felt  at  the  same  time  as  well  as  in  rotating 
the  arm,  if  the  middle  finger  is  placed  upon  the  site  of  the  coracoid,  the 
thumb  upon  the  posterior  surface  of  the  arm. 

Prognosis. — The  prognosis  is  favorable  even  if  some  displacement 
remains.  Commonly  abduction  is  somewhat  impaired.  The  period 
required  for  union  is  usually  from  ten  to  twelve  weeks.  A  few  cases 
have  recovered  with  pseudarthrosis. 

Treatment. — Reduction  is  by  upward  pressure  upon  the  humerus;  re- 
tention is  effected  by  means  of  an  axillary  pad,  with  an  appropriate 
bandage  supporting  the  elbow  (Desault's  dressing — Lotzbeck);  plaster 
splint  (Konig);  Middeldorpf's  triangle.  Sayre's  adhesive-plaster  dress- 
ing is  largely  used  at  the  present  time.  Bardenheuer  recommends 
his  spring-extension  splint  or  the  recumbent  position  and  upward  and 
outward  traction  on  the  adducted  arm.  From  personal  experience  the 
author  can  recommend  suspension  of  the  arm  with  the  patient  in  the 
lateral  position.  [Stimson  recommends  his  splint  used  for  dislocation 
of  the  acromial  end  of  the  clavicle,  carrying  the  strips  further  inward  on 
the  shoulder,  but  questions  the  ability  of  any  dressing  to  retain  the 
fragments  exactly.] 

Fracture  of  the  Acromion  and  Spine. — Fractures  of  the  acromion 
and  spine  are  not  infrequent  on  account  of  their  exposed  position.  In 
IS  fractures  of  the  scapula  Lonsdale  gives  8  of  the  acromion.  The 
cause  is  usually  direct  violence,  as  by  striking  the  top  of  the  shoulder 
in  falling;  rarely  indirect,  as  in  falling  upon  the  arm  or  by  strong  con- 
traction of  the  deltoid  (Michou).  The  line  of  separation  is  usually 
transverse;  by  direct  force  it  is  nearer  the  joint,  by  indirect  force 
nearer  the  base.  In  youth  these  fractures  are  replaced  by  separation 
of  the  epiphysis.  The  periosteum  often  remains  intact,  especially  on 
the  under  surface. 

Symptoms  and  Diagnosis. — Fracture  of  the  acromion  is  characterized  by 
local  pain  increased  by  pressure  or  elevation  of  the  arm.  In  the  absence 
of  displacement  there  is  no  deformity.  With  marked  projection  of  the 
fragment  the  condition  may  resemble  upward  dislocation  of  the  clavicle. 
Occasionally  the  cleft  can  be  felt,  especially  on  pulling  the  arm  down- 
ward.    Crepitus  is  obtained  by  lifting  the  arm. 


FRACTURES  OB   THE  SCAPULA.  45 

Prognosis. — Union  requires  from  four  to  five  weeks.  The  prognosis 
is  usually  favorable.  Rarely,  pseudoarthrosis  occurs,  bul  it'  firm  produces 
no  functional  disturbance. 

Treatment. — The  treatment  is  similar  to  that  of  supra-acromial  dis- 
location of  the  clavicle. 

Fractures  of  the  Coracoid  Process.  Fracture  of  thecoracoid  pro<  ess 
is  one  of  the  rarest  of  bone  fractures,  and  is  usually  accompanied  by 
other  injuries  of  the  scapula  and  clavicle,  or  complicates  dislocation 
of  I  la-  humerus.  The  base  of  the  process  is  the  common  seat  of 
fracture.  Any  great  displacement  presupposes  rupture  of  the  coraco- 
acromial  and  coracoclavicular  ligaments. 

Etiology. — The  cause  is  usually  direct  violence — blow  from  a  wagon- 
pole,  kick  of  a  horse — but  there  are  instances  in  which  the  fracture  was 
produced  by  indirect  violence,  especially  muscular  traction  (wringing 
out  wash,  throwing,  forced  supination — Holmes,  Gurltj.  Bennett 
records  a  case  of  epiphyseal  fracture  of  the  coracoid  from  tetanic  con- 
vulsions in  a  child  of  six  years. 

Symptoms. — The  symptoms,  in  the  absence  of  dislocation,  are  chiefly 
local  pain,  extravasation  of  blood  in  the  region  of  the  coracoid,  abnormal 
mobility,  and  crepitus.  Pain  is  felt  chiefly  on  deep  inspiration  and 
in  elevating  the  arm,  as  the  pectoralis  minor  thereby  pulls  upon  the 
process;  also  in  flexion  of  the  supinated  forearm  from  traction  of  the 
short  head  of  the  biceps;  with  the  forearm  pronated,  pain  is  absent, 
as  the  biceps  is  then  inactive.  Any  considerable  displacement  of  the 
process  is  dependent  upon  laceration  of  the  ligaments.  Then  the 
pectoralis  minor,  biceps,  and  coracobrachialis  draw  it  downward  and 
inward.  Usually,  however,  as  mentioned,  other  severe  injuries  are 
present  so  that  the  symptoms  of  fracture  of  the  coracoid  process  are 
obscured. 

Treatment. — Fixation  of  the  arm  in  acute  flexion  with  a  sling  or 
Yelpeau  bandage.  [Theoretically  the  best  position  of  the  arm  to  relax 
the  muscular  traction  on  the  process  would  be  in  acute  flexion  across 
the  chest,  the  hand  resting  on  the  other  shoulder.  The  consequent 
discomfort,  however,  may  compel  modification.] 

Gunshot-fractures  of  the  Scapula. — Gunshot-fractures  of  the  scapula 
are  relatively  frequent.  The  lesion  may  be  a  mere  perforation  or  a 
comminuted  fracture  with  many  fissures.  The  adjacent  structures — 
clavicle,  shoulder-joint,  ribs,  lungs,  etc. — may  be  involved,  especially 
by  shots  directly  forward  or  backward.  Among  the  numerous  scapular 
wounds  in  the  South  African  War  Kiittner  saw  only  one  case  of  splinter- 
ing; sensitiveness  to  pressure,  however,  was  always  extensive  and  indic- 
ative of  fissures.  The  injury  may  occur  by  way  of  the  axilla,  as  ob- 
served once  by  Stromeyer.  If  infection  takes  place,  the  fascial  arrange- 
ment about  the  overlapping  muscles  is  peculiarly  favorable  to  the 
development  of  extensive  gravitation  abscesses. 


46        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


CONTUSIONS  AND    SPRAINS  OF   THE   SHOULDER-JOINT. 

Contusions  and  sprains  of  the  shoulder-joint  are  frequent  injuries 
which  demand  the  careful  attention  of  the  surgeon,  as  they  often  give 
rise  to  persistent  functional  disturbances  that  are  out  of  all  proportion 
to  the  presumably  slight  primary  injury.  Among  the  cases  regarded 
as  sprains  are  unquestionably  some  in  which  small  fragments  of  bone 
have  been  chipped  from  the  glenoid  margin  or  in  which  the  capsule 
is  torn.  Even  contusions  are  very  apt  to  be  followed  by  stiffness  and 
especially  by  impairment  of  abduction.  The  pain  causes  the  patient 
to  hold  the  arm  guardedly  against  the  chest,  and  frequently  the  sur- 
geon, uncertain  as  to  the  treatment  required  or  misguided  by  a  wrong 
diagnosis,  immobilizes  the  arm  in  this  position  for  some  length  of  time. 
A  few  weeks  of  such  treatment,  aided  by  the  traumatic  infiltration  of 
the  tissues,  suffice  to  constrict  the  capsular  pouches,  which  facilitate 
the  free  movements  of  the  shoulder,  to  such  an  extent  that  combined 
with  the  adhesions  forming  in  the  subdeltoid  bursa  and  the  shortening 
of  the  adductors,  free  elevation  of  the  arm  is  irrevocably  lost.  In 
Germany  modern  accident  legislation  has  not  only  brought  the  atten- 
tion of  the  profession  to  the  unhappy  results  of  slight  shoulder-injuries, 
but  in  addition  has  been  directly  influential  in  increasing  the  percent- 
age of  bad  results,  in  that  it  has  caused  the  patients  to  do,  consciously 
or  unconsciously,  the  very  things  that  hinder  recovery.  Thiem,  in  his 
text-book  of  accident  surgery,  has  ably  characterized  the  disastrous 
influence  of  modern  legislation  upon  the  prognosis  of  shoulder  injuries. 
The  secret  of  success  in  the  prophylaxis  of  joint  stiffness  lies  in  insti- 
tuting motion  from  the  first  day.  The  measures  will  be  discussed  later 
under  contractures  of  the  shoulder-joint.  According  to  Dittmer,  of 
28  cases  of  sprain  of  the  shoulder,  only  5  were  cured  by  an  average 
treatment  of  9.4  months;  after  thirteen  months  in  23  cases  there  was 
still  an  average  disability  of  21.4  per  cent. 


WOUNDS  OF  THE  SHOULDER-JOINT. 

Wounds  of  the  shoulder-joint  are  produced  by  sharp  and  pointed 
instruments  and  firearms.  Although  puncture  wounds  are  not  in- 
frequent, very  few  cases  are  recorded  in  which  the  joint  has  been  opened 
from  above  by  incised  wounds  cleaving  the  shoulder  or  separating 
the  head  of  the  humerus  from  its  shaft.  From  the  site  of  the  injury 
one  can  make  a  probable  diagnosis  and  assume  an  injury  of  the  joint 
if  a  vertical  puncture  wound  is  situated  at  the  outer  side  of  the  coracoid 
process.  A  puncture  wound  extending  downward  and  outward  from 
the  inner  side  of  the  coracoid  process  will  probably  involve  the  glenoid 
margin  or  the  head  of  the  humerus.  Naturally  the  position  of  the  arm 
at  the  moment  of  injury  is  important.  For  example,  if  the  arm  is 
elevated  the  contracted  and  thickened  deltoid  may  be  perforated  without 


Wnl'.XPS  <>F  TUK  KIWULDEH  JOIST. 


47 


the  foinl  being  involved;  when  the  arm  hangs  down,  the  capsule  is 
thrown  into  folds  in  the  axilla,  so  that  a  horizontal  puncture  or  shot- 
wound  may  injure  the  capsule  and  not  the  hour. 

Discharge  of  synovial  fluid  has  been  demonstrated  in  very  few  cases. 
The  post-traumatic  inflammation  is  usually  the  first  sign  of  joint  involve- 
ment, so  that  cases  that  progress  favorably  from  the  outset  are  often 
not  recognized  as  joint  injuries. 

Gunshot-wounds. — Gunshot-wounds  are  the  most  important  and 
almost  the  only  injuries  in  war  involving  the  shoulder-joint.  They  are 
not  infrequent,  about  1.3  to  3.4  per  cent,  of  all  gunshot-wounds,  10.5 
to  1.").'.)  per  cent,  of  the  shot-wounds  of  the  joints. 

The  left  shoulder  is  injured  more  often  than  the  right,  as  the  latter 
is  protected   by  the  gunstock  while   firing.     The   ball    usually  enters 


Fig.  18. 


Fig.   19. 


Fig.  20. 


Resection  specimens  from  Franco-Prussian  War.      (v.  Bruns.) 
FlG.  18. — Ounshot-fraeture  of  the  head  of  the  femur,  with  extensive  splintering. 
Fi<;.  19. — Gunshot-wound  of  the  epiphyseal  line,  witli  Assuring  of  the  head. 

FlG.  20.— Gunshot -fracture  of  the  shaft  (butterfly  fracture),  with  separation  of  the  epiphysis 
and  Assuring  of  the  head. 


downward  to  the  outer  side  of  the  coracoid  process  and  emerges  behind 
near  the  teres  minor.  The  arch  of  the  shoulder  may  be  broken  with 
or  without  injury  of  the  capsule,  or  the  capsule  alone  may  be  affected. 
We  distinguish:  wounds  of  the  capsule;  furrowT  wounds,  in  which 
the  articular  head  or  the  glenoid  cavity  show  only  a  groove;  pene- 
trating wounds  with  or  without  fissures.  (Fig.  19.)  The  old  leaden 
bullets  usually  produced  comminuted  fractures,  the  bone  being  more 
or  less  splintered,  especially  by  close-range  shots.  (Fig.  IS.)  The 
modern  metal-coated  bullet  as  a  rule  produces  a  penetrating  or  furrowed 
wound  in  the  head  of  the  humerus.  (Kiittner.)  The  involvement  of 
the  joint  is  surprisingly  slight.  Further,  we  distinguish  perforating 
wTounds,  the  most  common  form  produced  by  the  modern  bullets,  and 


48        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

those  with  enlodgement  of  the  bullet.  Gunshot-wounds  of  the  joint 
are  produced  indirectly  by  fissures  radiating  to  the  joint  from  a  gunshot 
fracture  of  the  humerus  or  scapula.  (Fig.  20.)  In  young  subjects  the 
cartilaginous  epiphyseal  disk  may  interrupt  a  fissure  emanating  from  the 
diaphysis.  The  dislocations  and  subluxations  seen  in  rare  cases  result- 
ing from  lead-bullet  injuries  do  not  apply  to  metal-coated  bullets. 

Prognosis. — The  prognosis  of  shot-wounds  of  the  shoulder-joint 
depends  upon  two  factors:  the  nature  of  the  injury,  depending  in  turn 
upon  the  weapon;  and,  more  important,  the  primary  treatment.  Com- 
plications— that  is,  injuries  of  the  adjacent  structures — may  exercise 
naturally  a  priori  an  incalculable  influence.  The  mortality  statistics 
of  earlier  wars  are  to-day  valueless. 

Treatment. — The  primary  aseptic  occlusion  as  proposed  by  v.  Berg- 
mann  applies  to  the  shoulder-joint  as  well  as  to  other  parts.  Kiittner 
emphasizes  the  value  of  immobilization.  If  recovery  is  uninterrupted, 
it  is  continued  for  four  weeks,  to  be  replaced  later  by  medico-mechanical 
treatment.  He  obtained  good  functional  results.  The  favorable  results 
of  conservative  treatment  were  recorded  as  early  as  the  Franco-Prussian 
War  by  Ernesti — c.  g.,  36  per  cent,  of  partially,  10  per  cent,  of  freely 
movable  shoulder-joint,  and  a  mortality  of  10  per  cent. 

It  is  well  known  that  a  lodged  bullet  is  not  an  indication  per  se  for 
primary  interference. 

Primary  resection,  so  prominent  in  the  treatment  of  wounds  in  earlier 
wars,  is  to-day  the  exception.  In  cases  of  severe  comminution  and 
extensive  injury  of  the  soft  parts  it  is  advisable  to  remove  all  splinters, 
shreds  of  tissue,  foreign  substances,  restore  the  parts  to  their  normal 
relation  as  far  as  possible,  and  to  pack  the  wound  lightly,  and  to  drain 
thoroughly.  All  necessary  incisions  should  avoid  functionally  important 
structures  if  possible.  Careful  ligation  and  the  least  possible  manipu- 
lation of  the  wound  are  regarded  now  as  important  details  in  the  treat- 
ment. 

The  treatment  of  an  intercurrent  infection  and  of  cases  already 
infected  will  be  considered  later  under  Purulent  Inflammation  of  the 
Shoulder-joint. 

Amputation  at  the  shoulder  is  indicated  only  in  cases  with  severe 
injury  of  the  extremity,  of  the  large  vessels  and  nerves,  or  occasionally 
in  injuries  from  large  projectiles.  The  great  frequency  of  this  operation 
in  earlier  wars — Pirogoff  cites  30  cases  after  the  first  bombardment  of 
Sebastopol — is  reduced  at  the  present  time  by  the  better  prognosis  of 
conservative  treatment  and  resection.  It  was  seldom  performed  in 
recent  wars.  In  31  cases  of  artillery- wounds  and  6S  of  rifle- wounds  of 
the  upper  extremity  Kiittner  and  Matthiolius  were  obliged  to  do  only 
one  amputation,  and  that  in  the  case  of  a  man,  seen  for  the  first 
time  on  the  sixteenth  day,  with  suppuration  of  the  wrist-joint  and  well- 
developed  sepsis.  All  other  injuries  of  the  large  joints  of  the  arm 
(7)  recovered  without  operation. 


FRACTURES  OF  UPPER  END  OF  UPPER  EXTREMITY. 


49 


FRACTURES  OF  THE  UPPER  END  OF  THE  UPPER  EXTREMITY. 

Fractures  of  the  humerus  in  general  have  a  frequency  of  7  per  cent. 
The  upper  and  lower  ends  arc  involved  about  equally  often;  the 
diaphysis  twice  as  often,  according  to  Bruns.  In  61  cases  Poirier  saw 
the  upper  part  involved  41  times,  the  lower  12  times,  the  middle  15 
times. 

Fracture  of  the  upper  end  of  the  humerus  occurs  most  frequently  in 
advanced  age,  when  the  resistance  of  the  bone  is  diminished,  and  in 
youth  from  the  lesser  resistance  of  the  epiphyseal  line.  Men  are  oftener 
affected  than  women — 35  to  2,  according  to  Decamp. 


Fig.  22. 


Fig.  23. 


Pig.  21.— 1.  Fracture  of  the  anatomical  neck.  2.  Fracture  through  the  tuberosities  (pertuber- 
cularis).     3.  Fracture  of  the  surgical  neck. 

Fig.  22.— Fracture  of  the  anatomical  neck  and  through  the  tuberosities  (Y-fracture  with  dis- 
placement and  abduction). 

Fig.  23.— Fracture  below  the  tuberosities  (subtubercularis),  with  abduction  and  impaction 
(front  view). 

Kocher  distinguishes  the  following  forms,  according  to  the  anatomical 
position : 

Supratubercular  (intracapsular)  fractures: 

1.  Fracture  of  the  head. 

2.  Fracture  of  the  anatomical  neck.     (Fig.  21,  1.) 
Inf ratubercular  fractures : 

1.  Fractura  pertubercularis,  including  fracture  of  the  epiphyseal 

line.     (Fig.  21,  2.) 

2.  Fractura  subtubercularis,  corresponding  to  fracture  of  the  sur- 

gical neck.     (Fig.  21,  3.) 

3.  Y-fracture,  by  combination  of  two  lines  of  fracture. 

4.  Isolated  fracture  of  the  greater  or  lesser  tuberosity. 

The  fracture  line  is  usually  transverse,  less  often  oblique  or  markedly 
zigzag.  According  to  the  cause,  we  distinguish  compression,  abduc- 
tion, adduction,  flexion,  extension,  and  torsion  fractures.  Compres- 
sion fractures  may  be  supratubercular  or  infratubercular.  Fracture 
by  bowing  is  always  infratubercular,  as  during  a  blow  or  movement 
Vol.  III.— 4 


50       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

only  that  part  of  the  head  is  fixed  which  lies  within  the  capsule  and 
tendinous  attachments.  The  pure  supra  tubercular  forms  are  rare;  the 
combined  forms,  partly  supratubercular,  partly  infratubercular,  are 
frequent,  the  subtubercular  more  so.  The  combined  forms  are  easily 
produced  by  pressure  from  without  and  from  beneath,  as  Kocher 
demonstrated  on  the  cadaver. 

Fractures  of  the  upper  end  of  the  humerus  are  often  without  any 
marked  displacement;  occasionally  they  are  impacted,  the  fracture 
surface  of  the  neck  being  driven  into  the  spongiosa  of  the  head. 

Supratubercular  and  Intracapsular  Fractures  of  the  Humerus. 

Fracture  of  the  head  of  the  humerus  may  be  complete  or  incomplete, 
the  latter  in  the  form  of  fissures  or  partial  avulsion  of  the  small  frag- 
ments. 

Fig.  24. 


,  ■ 


Fracture  of  the  anatomical  neck.     (Anger.) 


Fractures  of  the  Anatomical  Neck. — Fracture  of  the  anatomical 
neck  is  the  only  typical  form,  and  is  less  frequent  than  that  of  the 
surgical  neck — according  to  Albert,  in  the  ratio  of  1  to  20.  It  occurs 
more  particularly  in  older  individuals  on  account  of  the  rarefaction 
of  bone.  The  head  may  be  impacted  and  at  the  same  time  displaced 
upward  or  downward;  it  may  be  luxated  or  completely  rotated  and  lie 
with  the  fracture  surface  against  the  glenoid  cavity. 

Symptoms. — Swelling  and  deformity  are  usually  slight.  Pain,  as  in 
all  joint  fractures,  is  marked,  and  is  increased  by  passive  motion. 
Equally  characteristic,  according  to  Kocher,  is  the  immediate,  complete, 
and  persistent  loss  of  function.  As  a  rule  ecchymosis  appears  later — 
at  the  end  of  one  or  two  days — beginning  on  the  inner  surface  of  the 
arm  and  then  spreading  in  the  usual  manner.  On' palpation  the  head 
is  found  sensitive  to  pressure.     A  blow  on  the  elbow  produces  severe 


FRACTURES  OF  UPPER   END  <>E  UPPER   EXTREMITY. 


51 


pain.  By  abduction  ami  pressure  in  the  axilla  pain  and  crepitus  ran 
be  elicited,  especially  on  rotating  the  arm.  Pain  and  crepitus  are  absent 
with  impaction.  Sometimes  the  mobility  of  the  fragment  can  be  felt. 
\\C  examine  for  flattening  of  the  shoulder,  shortening,  and  the  ability 

to  draw  the  arm  downward  more  easily  than  normally.  The  condition 
is  differentiated  from  fracture  of  the  surgical  neck  by  placing  the  end  of 
the  finger  under  the  acromion  and  verifying  the  movement  of  the 
tuberosity  with  the  rotated  arm.  No  displacement  of  the  head  is  palpable 
as  it  is  in  dislocation.  Absence  of  "elastic"  fixation  of  the  arm  is 
important  for  the  differential  diagnosis  from  dislocation. 

Prognosis. — The  prognosis  of  fracture  of  the  anatomical  neck  is 
doubtful;  complete  recovery  is  rare.  Union  lias  occurred  even  with 
complete  rotation  of  the  head,  as  usually  some  parts  of  the  capsule  and 
periosteum  are  still  attached  to  it.  Ankylosis  results  more  frequently, 
especially  after  inflammatory  infiltration.  If  the  capsule  and  the  anterior 
circumflex  artery  are  torn,  necrosis  of  the  upper  fragment  follows. 


Fig.  25. 


Fig.   20. 


Fig.  27. 


Pig.  25.— Fracture  through  the  tuberosities,  with  adduction  ami  impaction    front  view  I. 
Fig.  26.— The  above  seen  from  the  inner  side,  with  tin-  arm  extended. 

Pig.  27.— Fracture  through  the    tuberosities,  with    abduction  and    displacement   of   the  shaft 
forward  and  inward. 


Treatment. — The  treatment  of  supratubercular  fracture  is  occasionally 
simple.  Impacted  fractures  merely  require  a  sling;  later,  careful  mas- 
sage and  exercise.  Bardenheuer  claims  good  results  in  four  to  five 
weeks  by  the  extension  method.  The  tendency  of  the  humerus  to  be 
displaced  toward  the  coracoid  process  is  counteracted  by  outward  trac- 
tion or  by  a  pad  in  the  axilla  combined  with  fixation  of  the  arm  across 
the  chest  and  downward  traction. 

Where  intracapsular  displacement  of  a  fragment  occurs,  Kocher 
ail  vises  removal  of  the  latter  as  the  most  rational  and  the  only  successful 
treatment.  In  many  cases  operative  interference  is  required  secondarily 
for  necrosis.  Above  all,  the  treatment  should  aim  to  prevent  joint 
stiffness.  For  this  reason  bandages  should  not  be  too  rigid  nor  applied 
too  long,  and  massage  and  muscular  exercise  should  be  begun  early 
and  be  continued  for  some  time. 


52        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

Infratubercular  Fractures  of  the  Humerus. 

Fracture  through  the  Tuberosity. — Fractura  pertubercularis  is 
caused  by  a  blow  upon  the  shoulder  from  the  side,  or  upon  the 
elbow  or  shoulder  from  below  and  from  the  side  while  the  arm  is 
adducted. 

Fracture  by  adduction  is  thus  frequent  (Figs.  25  and  26);  as  the  head 
is  held  firmly  by  the  ligaments  and  capsule,  a  blow  upon  the  elbow 
forces  the  arm  inward  and  backward  so  that  the  upper  end  of  the  shaft 
is  displaced  forward  or  forward  and  outward.  Fracture  by  abduction 
is  less  common.     (Fig.  27  )     Impaction  is  frequent.     (Fig.  25.) 

Fig    28. 


Fracture  through  the  tuberosities,  with  reversal  of  the  head.     (v.  Bruns.) 

Fracture  of  the  Epiphysis. — Fracture  or  separation  of  the  epiphysis 
is  essentially  the  primal  form  of  pertubercular  fracture.  Disregarding 
its  occurrence  in  the  newborn,  in  whom  the  separation  is  usually  subtu- 
bercular,  it  is  most  frequent  from  the  tenth  to  the  twentieth  year.  In 
49  epiphyseal  fractures  Bruns  saw  21  of  the  upper  end  of  the  humerus. 
The  head  and  greater  tuberosity  each  have  a  primary  centre  and  unite 
in  the  fifth  year  to  form  the  epiphysis.  The  latter  unites  with  the  shaft 
in  the  twentieth  year. 

Separation  of  the  epiphysis  is  usually  caused  by  direct  violence,  such 
as  a  fall  upon  the  shoulder;  in  the  newborn  by  traction  upon  the  arm 
— solutio  brachii. 


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FRACTURES  OF  UPPFJl  ESI)  OF  UPPER  EXTREMITY. 


53 


The  anatomical  conditions  found  in  fracture  of  the  epiphysis 
namely,  the  peculiar  nodular  surface  of  the  upper  end  of  the  shaft  and 
the  rupture  of  the  periosteum,  at  times  incomplete— are  shown  some- 
what diagrammatically  in  Fig.  ~2\).  The  separation  always  occurs  in 
the  transition  stratum  between  the  cartilage  and  shaft.  In  older 
children  a  wedge-shaped  piece  of  the  shaft  is  not  uncommonly  torn 
off  with  the  epiphysis.     (Fig.  30.) 

Symptoms — The  symptoms  are  sometimes  trifling.  In  the  new  horn, 
loss  of  function  and  pain,  which  is  increased  l>y  rotation.  Displacement 
is  often  slight,  the  curve  of  the  shoulder  being  normal.  In  most  of  the 
cases  the  end  of  the  shaft  is  displaced  upward,  inward,  and  forward  by 
muscular  traction,  forming  an  angular  prominence  best  seen  from  the 
side  or  above.  The  skin  may  he  empaled  or  perforated.  Kiistner  has 
noted  a  marked  outward  rotation  of  the  epiphysis.  Crepitus  is  com- 
monly present;  in  young  children  the  soft  cartilaginous  crepitus,  in  older 
children  the  usual  bony  crepitus. 


Separation  of  the  epiphysis.     Periosteum  partly  intact.     (Thudicum.) 


Diagnosis. — Fracture  of  the  epiphysis  in  young  children  is  easily  over- 
looked, as  the  symptoms  are  insignificant,  the  shoulder  contour  normal, 
the  displacement  slight.  In  older  children,  the  evident  deformity,  the 
striking  deviation  of  the  axis  of  the  shaft  forward,  the  palpable  edge  of 
the  shaft,  and  the  crepitus  are  usually  so  characteristic  that  the  diagnosis 
is  simple.  Still  the  author  has  seen  a  few  cases  in  which  the  differential 
diagnosis  from  fracture  of  the  surgical  neck  was  only  possible  with  the 
.r-rav.  The  presence  of  the  head  in  its  normal  position  is  against 
dislocation;  if  held  between  the  fingers  while  the  arm  is  rotated,  the 
head  does  not  follow  the  movements  of  the  latter.  The  deformity 
is  easily  overcome  by  traction,  but  returns  immediately  when  the  latter 
ceases. 

Prognosis. — With  proper  treatment  the  prognosis  is  favorable.  Even 
if  accompanied  by  avulsion  of   parts  of   the   shaft   the   shortening  is 


54       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

slight  if  the  epiphyseal  cap  is  properly  readjusted.  If  the  displacement 
persists,  defects  in  growth  follow  which  are  severe  in  direct  relation  to 
the  youth  of  the  patient.  In  the  Tubingen  clinic  the  shortening  observed 
in  untreated  cases  varied  from  2f  to  51  inches. 

Treatment. — Proper  coaptation  of  the  epiphysis  to  the  shaft  is  of  the 
utmost  importance.  A  plaster  splint  suffices  for  cases  without  displace- 
ment. If  there  is  a  tendency  to  displacement  the  best  method  is  trac- 
tion or  vertical  suspension.  The  latter  failing,  operative  reduction  and 
fixation  are  indicated.  The  extension  method  is  also  applicable  to  cases 
operated  upon  for  malunion. 

Fracture  of  the  Surgical  Neck. — Fracture  of  the  surgical  neck 
(fractura  colli  chir.,  fractura  subtubercularis)  is  the  most  frequent 
fracture  of  the  upper  end  of  the  shaft.     It  occurs  most  commonly  at 

Fig.  30. 


Separation  of  the  epiphysis,  with  an  oblique  fragment  from  shaft.     Outward  displacement 

of  shaft,     (v.  Bruns.) 


the  point  of  transition  between  the  cancellous  and  spongy  bone  of  the 
shaft— namely,  between  the  tuberosity  and  the  insertion  of  the  pectoralis 
major.  In  the  majority  of  cases  it  is  an  abduction  fracture  produced 
by  direct  violence — a  blow  or  fall  upon  the  outer  side  of  the  shoulder. 
It  results  also  from  falling  upon  the  elbow  and  from  muscular  traction. 
The  line  of  fracture  is  usually  transverse,  rarely  oblique;  it  may  extend 
within  the  capsule.  Transverse  and  oblique  fractures  are  often  serrated 
or  comminuted.  Smaller  pieces  of  bone  may  be  chipped  off.  The  sur- 
faces may  be  impacted,  the  lower  end  being  driven  bluntly  or  pointedly — 
usually  the  inner  edge — into  the  spongiosa  of  the  upper  fragment.  The 
reverse  mechanism  is  rare.  (Fig.  34.)  Oblique  fractures  often  damage  the 
soft  parts;  empalement  of  the  muscles  is  frequent;  rupture  of  the  biceps 
tendon  and  injuries  of  the  nerves  and  vessels  are  rare.  With  marked 
displacement  of  the  fragments  the  soft  parts — deltoid  and  biceps  tendon 


FRACTURES  OF   UPPER   KM)  OF   UPPER   EXTREMFTY. 


55 


— may  become  interposed.  The  skin  may  be  empaled  or  perforated. 
It'  the  lower  fragment  is  freely  movable,  it  may  he  displaced  inward  by 
the  pectoralis  or  latissimus,  or  upward  by  the  deltoid;  the  upper  frag- 
ment is  drawn  slightly  outward  by  the  teres  minor.  The  displacement, 
however,  is  often  influenced  by  the  nature  and  direction  of  the  violence 
in  such  a  way  as  to  prevent  the  typical  action  of  the  muscles. 

Symptoms. — Abduction  being  the  most  frequent  position  of  the  lower 
fragment,  the  symptoms  are  very  similar  to  those  of  dislocation:  flat- 
tening of  the  shoulder  with  a  depression  at  about  the  deltoid  insertion. 
Loss  of  function  is  evident.     Pain  and  swelling  are  moderate.     Short- 


Fig.  31. 


Fig.  32. 


Separation  of  the  epiphysis,  with  malunion, 
dating  from  first  year.  Aged  twelve  years, 
(v.  Brims.) 


Impacted  fracture  of  the  humerus  through 
the  tuberosities.     (R.  W.  Smith.) 


ening  is  usually  noticeable — 1  to  2  inches.  The  arm  admits  of  free 
passive  motion,  and  in  the  absence  of  impaction  false  motion  is  easily 
obtained  by  holding  the  head  between  the  fingers  and  moving  the  arm. 
At  the  same  time  crepitus  is  felt  if  the  ends  are  not  separated  by  inter- 
posed muscle.  In  the  axilla  the  lower  fragment  is  palpable  and  rotates 
with  the  arm,  while  the  head  is  felt  to  be  in  place. 

Bearing  these  symptoms  in  mind,  the  condition  cannot  be  confused 
with  dislocation.  An  accurate  determination  of  the  level  of  the  fracture 
line,  however,  may  be  difficult  if  the  soft  parts  are  thick.     The  x-ray 


56       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


has  frequently  convinced  the  author  of  error  in  this  respect  to  the  extent 
of  several  fingers'  breadth. 

Prognosis. — The  prognosis  is  usually  favorable;  union  is  complete  in 
from  four  to  six  weeks.  Pseudarthrosis  is  rare.  So  are  severe  compli- 
cations, such  as  suppuration  of  the  joint,  paralysis  of  the  nerves  of  the 
arm,  or  gangrene  from  compression,  or  injury  of  the  large  vessels  of  the 
axilla.    The  mobility  of  the  arm  may  be  permanently  impaired. 

Disregarding  the  direct  involvement  of  the  joint  by  supratubercular 
fissures,  its  proximity  to  the  fracture  is  sufficient  to  explain  the  traumatic 
irritation  and  the  stiffness  that  follow,  just  as  from  simple  contusions. 
Occasionally  motion  is  limited  in  certain  directions  by  exuberant  callus 
or  malunion  with  angular  deformity,  as  in  adduction  or  with  rotary 
displacement. 


Fig.  33. 


Fig.  34. 


Impaction  of  the  head  of  the  humerus  into 
the  shaft,  with  splitting  off  of  the  tuberosities. 
(R.  W.  Smith.) 


Fracture  of  the  surgical  neck,  with 
impaction,     (v.  Bruns.) 


Treatment. — The  treatment  of  fracture  of  the  neck  without  displace 
ment  is  simple:  moulded  strips,  starch  bandages,  an  axillary  pad,  and 
a  sling  are  sufficient.  The  latter  should  support  the  wrist  only,  not  the 
elbow,  to  permit  extension  of  the  arm  by  gravity.  The  reduction  of 
marked  displacement  will  require  appropriate  downward  or  lateral  trac- 
tion or  pressure.  The  splint  should  exert  continuous  traction.  For 
severe  cases  the  horizontal  extension  method,  as  recommended  by  Bar- 
denheuer,  is  most  satisfactory.  For  ambulant  cases  the  two-strip  splint 
may  be  combined  with  extension  as  for  supracondyloid  fractures  of  the 
lower  end  of  the  shaft  (which  see).    In  general  the  author  prefers  vertical 


FRACTURES  OF  UPPER  END  OF  UPPER  EXTREMITY.         57 

Suspension  in  the  Literal   position.      Its  action   is  certain   if  sufficient 
weight  is  used.     The  general  rule  for  extension  by  weight  applies  here 


Pig.  35. 


Fig.  36. 


Fracture  of  the  upper  end  of  the  humerus.     Note  hand,  forearm,  and  elbow  bandaged; 
axillary  pad  and  strap.     (Scudder  on  Fractures.) 


as  in  all  fractures — namely,  to  use  heavy  weights  at  first  (Bardenheuer 
advises  twenty  pounds  in  the  first  two  days)  to  overcome  muscular 
contraction,  and  later  only  sufficient  to  maintain  the  fragments  in  posi- 


58        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

tion.  In  suspension  the  weight  acts  only  when  it  is  heavier  than  the 
arm;  the  latter  in  the  adult  weighs  about  seven  and  a  half  pounds, 
according  to  Harless. 

Clark  believes  that  extension  is  less  effectual  in  ambulant  cases. 
Traction  is  removed  for  the  recumbent  cases  in  from  eight  to  fourteen 
days;  an  extension  strip  splint  is  applied  and  the  patient  is  made  ambu- 
lant. The  ambulant  treatment  is  better  from  the  outset  if  the  tendency 
to  displacement  is  slight  or  if  for  any  reason  the  recumbent  position  is 
inadvisable — namely,  in  the  case  of  elderly  subjects. 

Operative  interference  is  rarely  necessary;  axillary  complications 
should  receive  appropriate  treatment.     Exceptionally,  irreducible  frac- 

Fig.  38. 


Fracture  of  the  upper  end  or  shaft  of  the  humerus.     Posterior  view.     Note  bandage  to  forearm 
and  elbow  ;  axillary  pad  and  strap.     Note  shape  of  axillary  pad.     (Scudder  on  Fractures.) 


tures  will  require  incision  and  suture.  Rehn  cites  2  such  cases  with 
good  results.  The  author  advises  operation  in  all  compound  fractures 
with  severe  damage  of  the  soft  parts,  even  if  resection  is  unnecessary. 
Operation  may  be  required  secondarily  to  excise  a  projecting  portion 
of  the  lower  fragment  limiting  motion,  or  to  do  an  osteotomy  of  the 
fracture  with  secondary  suture.  At  the  present  time  we  make  operation 
dependent  upon  the  findings  of  the  x-raj.  The  incision  should  have 
regard  for  the  later  function,  as  emphasized  by  Kocher,  and  if  possible 
be  made  at  the  anterior  deltoid  margin.  Fracture  of  the  neck  as  the 
frequent  complication  of  dislocation  of  the  shoulder  will  be  discussed 
with  shoulder  dislocations. 


FRACTURES  OF  UPPER   ESP  OF  UPPER   EXTREMITY. 


59 


Fracture  of  the  Tuberosities.  Fractures  of  the  .tuberosities  alone 
ni.iv  be  incomplete  or  complete;  they  are  usually  combined  with  other 
injuries.  The  greater  tuberosity  is  broken  off  most  frequently,  it 
may  be  torn  or  knocked  off  in  connection  with  dislocation  of  the 
shoulder.     Deuerlich  collected  17  cases  of  this  sort. 

The  tuberosity  may  be  torn  off  entirely;  or  only  the  two  anterior 
facets  or  the  posterior  facet.  (Gurlt.)  Longitudinal  fissures  have  been 
seen.  Usually  the  fracture  line  begins  at  the  level  of  the  anatomical 
neck;  exceptionally  a  piece  of  the  shaft  may  be  torn  off.  Interposition 
of  the  biceps  tendon  has  been  found  in  a  few  cases.  As  a  rule,  the 
tuberosity  is  drawn   upward  and  outward  from  1  to  1\  inches  by  the 


Fig.  39. 


Fig.  40. 


Fracture  at  upper  end  of  the  humerus.  Note 
hand,  forearm,  and  elbow  bandaged  ;  axillary 
pad  and  strap,  plaster-of-Paris  shoulder-cap, 
sling.     (Scudder  on  Fractures.) 


Fracture  at  upper  end  of  the  humerus.  Arm 
and  elbow  bandaged.  The  axillary  pad  and 
shoulder-cap  in  position.  Application  of  cir- 
cular bandage  to  trunk  and  shoulder.  Sling  not 
shown.     (Scudder  on  Fractures.) 


external  rotators.  Exceptionally  the  tuberosity  is  driven  between  the 
head  and  shaft  like  a  wedge.  The  cause  is  ordinarily  a  fall  upon  the 
shoulder  or  outstretched  hand,  rarely  the  forced  action  of  the  outward 
rotators  in  throwing  or  hurling  objects. 

Symptoms. — In  isolated  fracture  of  the  tuberosity  the  arm  is  sublux- 
ated  forward  and  can  be  rotated  inward  abnormally.  Outward  rotation 
is  impossible  actively,  but  possible  passively.  The  shoulder  appears 
broader  from  before  backward;  the  acromion  projects  sharply;  the 
tuberosity  is  displaced  downward  and  backward  from  the  latter,  and 
forms  a  distinct  prominence  separated  from  the  head  by  a  palpable 
groove.     It  is  tender  on  palpation  and  gives  crepitus  if  moved.     Asso- 


60       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


Fig.  4  ciated  with  dislocation  of   the  shoulder  it 

is  usually  first  recognized  during  reduc- 
tion, and  may  hinder  the  latter  if  it  lies 
in  the  glenoid  cavity;  it  may  be  evidenced 
after  reduction  by  a  surprising  tendency 
to  reluxation.  Union  occurs,  as  a  rule, 
with  a  certain  amount  of  displacement, 
giving  the  bone  the  forked  form  of  the 
upper  end  of  the  femur.  (Fig.  41.)  The 
broadening  of  the  upper  end  of  the  hume- 
rus may  impair  its  function,  especially 
rotation  and  abduction. 

Treatment. — The  effort  should  be  made 
to  replace  the  fragment  by  immobilizing 
the  arm  in  abduction  and  outward  rota- 
tion. With  Kocher  the  author  believes 
the  best  method  is  to  suture  or  nail  the 
fragment  back  in  place. 

Isolated  fracture  of  the  lesser  tuberosity 
is  rare.  Gurlt  cites  3  cases.  As  an  ac- 
companiment of  dislocation,  produced  by 
Old  fracture  of  the  greater  tuber-  the  action  of  the  subscapular  muscle,  it  is 
osity.    Arthritis  deformans  0f   the     somewhat  more  frequent.     The  fragment 

dislocated  head.      tv.  Bruns.)  .  .       ,  ,  ,,        .  •  1  »    ■ 

may  be  palpable  to  the  inner  side  of  its 
normal  position  and  give  crepitus.  Inward  rotation  is  impaired;  the 
biceps  tendon  may  be  torn  and  increase  the  functional  disturbance. 


DISLOCATIONS  OF  THE  SHOULDER. 


"'Dislocations  of  the  shoulder  are  the  most  frequent  of  all  dislocations: 
Kronlein  gives  the  relative  frequency  as  51.7  per  cent.;  Gurlt,  52.4  per 
cent.;  Bardenheuer,  54  per  cent.;  French  authors,  collectively,  55  per 
cent.  This  frequency  is  easily  explained  by  the  free  mobility;  the  exposed 
position;  the  anatomical  structure  of  the  joint,  whose  glenoid  surface  is 
three  to  four  times  smaller  than  the  surface  of  the  head;  and  by  the 
long  lever-arm  as  represented  by  the  entire  extremity. 

The  dislocation  is  most  common  in  middle  and  advanced  life,  between 
the  fortieth  and  sixtieth  year,  and  very  rare  in  childhood.  Men  are 
affected  four  to  five  times  more  often  than  women,  on  account  of  greater 
exposure  to  injury  in  their  occupations. 

Displacement  of  the  head  upward  is  prevented  by  the  acromion,  the 
coracoid  process,  and  the  coracoacromial  ligament-,  and  is  hardly  con- 
ceivable without  fracture  of  these  structures;  displacement  downward 
is  opposed  by  the  resistance  of  the  capsule  reinforced  by  the  long  head 
of  the  biceps,  hence  it  is  possible  for  the  head  to  leave  the  cavity  only 
forward  or  backward.  Dislocation  forward  occurs  much  oftener  than 
in  the  opposite  direction;  the  material  in  Brims'  clinic  gives  the  ratio 


DISLOCA  TIONS  OF  THE  SHOULDER.  Gl 

of  98  to  3.  According  to  the  level  at  which  the  head  lodges,  various 
subvarieties  may  be  classified.  To  distinguish  between  complete  and 
incomplete  dislocation  is  of  little  practical  importance,  the  latter  form 
being  rare. 

The  author  recommends  the  following  classification  as  most  practical: 

I.  Luxatio  anterior  or  prseglenoidea : 

1.  Subcoracoidea. 

2.  Axillaris  or  prseglenoidea  inferior. 

3.  Prsescapularis. 

4.  Infraclavicularis. 

II.  Luxatio  posterior  or  retroglenoidea: 

1.  Subacromialis. 

2.  Infraspinate  or  retroglenoidea  inferior. 

The  large  majority  of  dislocations  of  the  shoulder  are  typical,  being 
determined  by  the  integrity  of  the  strongest  parts  of  the  capsule,  espe- 
cially the  coracohumeral  ligament. 

Exceptionally,  from  extensive  laceration  of  the  capsule  or  avulsion  of 
the  tendon  insertions  and  bony  protuberances,  atypical  displacements 
of  the  head  occur,  which  Kocher,  following  Bigelow,  has  termed  "  irreg- 
ular "  dislocations  in  contrast  to  the  "regular"  forms.  They  belong 
among  the  forward  dislocations  and  will  be  described  with  them. 

Forward  (and  Downward)  Dislocations  of  the  Shoulder. 

Subcoracoid  Dislocation. — This  is  the  most  frequent  and  therefore 
most  important  dislocation  of  the  shoulder.  The  head  is  displaced  for- 
ward and  inward  and  lies  beneath  the  coracoid  process.  (Fig.  42.)  In 
some  instances  the  cause  is  direct:  a  blow  from  behind  or  a  fall — e.  g., 
against  the  edge  of  the  stairs;  more  frequently  indirect — a  fall  upon  the 
arm  outstretched  behind  or  upon  the  hand.  In  a  large  number  of  cases  it 
results  from  hyperabduction,  the  greater  tuberosity  being  pressed  against 
the  upper  margin  of  the  cavity,  the  surgical  neck  against  the  acromion,  the 
latter  thus  acting  as  a  fulcrum.  The  long  lever-arm,  the  entire  extremity, 
pries  the  short  arm,  the  head,  out  of  the  socket,  with  laceration  of  the 
lower  front  part  of  the  capsule.  The  dislocation  is  therefore  at  first 
downward  and  forward;  secondarily  the  arm  drops  and  the  head  is 
pushed  up  beneath  the  coracoid  process.  In  experimental  dislocation 
hyperabduction  alone  is  usually  not  sufficient,  but  must  be  combined 
with  rotation.  So  in  the  various  causes  of  production,  such  as  a  fall 
upon  the  hand  or  being  dragged  by  a  horse  while  holding  the  reins, 
there  is  commonly  a  rotary  factor.  Exceptionally,  muscular  action  is 
the  cause,  as  in  throwing,  or  by  a  false  thrust  or  swinging  blow,  as  in 
whipping,  or  epileptic  or  eclamptic  attacks. 

Axillary  Dislocation. — The  head  lies  upon  the  so-called  facies  sub- 
glenoidea,  the  surface  of  the  scapula  beneath  the  glenoid  margin  facing 
downward  and  formed  by  the  lateral  border  curving  backward  about 
f  inch.  This  surface  is  sufficiently  broad  to  form  a  support  for  the 
head.     In   the  causation    hyperabduction   plays   the   chief   part;    any 


62        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


Fig.  42. 


secondary  upward  movement  of  the  head  beneath  the  coracoid  process 
is  prevented  by  the  intact  anterior  portion  of  the  capsule.  Exceptionally 
the  arm  does  not  drop  secondarily,  giving  the  so-called  luxatio  axillaris 
erecta  of  Middeldorpf,  the  humerus  being  fixed  in  vertical  elevation. 
Finckh  reports  one  "erect"  case  in  201  dislocations  forward;  Kronlein, 
3  in  207.  By  the  continuation  of  the  force  in  the  direction  of  the  abducted 
arm  the  head  is  driven  further  down  against  the  chest.    In  some  instances 

the  dislocation  was  pro- 
duced by  violent  wrenching 
of  the  elevated  arm  in  the 
attempt  to  save  one's  self 
in  falling  from  a  height. 

The  subcoracoid  and  ax- 
illary forms  represent  92  per 
cent,  of  forward  disloca- 
tions; the  other  forms  are 
extremely  rare.  In  Finckh's 
201  cases  8  were  prescapu- 
lar,  2  infraclavicular.  Both 
of  the  latter  may  be  regarded 
as  an  accentuation  of  the 
inward  displacement  of  the 
head  in  preglenoid  disloca- 
tion. In  prescapular  dis- 
location the  head  lies  in  the 
subscapular  fossa  between 
the  subscapularis  and  the 
scapula,  or  it  may  perforate 
the  muscle.  The  infrascap- 
ularform,  in  which  the  head 
lies  close  beneath  the  clavi- 
cle to  the  inner  side  of  the 
coracoid  process,  presup- 
poses extensive  laceration  of 
the  capsule  and  muscular 
attachments  by  great  vio- 
lence, such  as  a  fall  from  a 
horse.  The  head  may  project  forward  and  lie  beneath  the  skin  in  the 
perforated  pectoralis,  as  noted  by  Tillaux;  or  it  may  push  the  clavicle 
forward  and  be  wedged  between  the  same  and  the  first  rib  until  it  pro- 
jects an  inch  above  the  clavicle. 

Anatomical  Findings  of  Forward  Dislocation. — Extravasation  of  blood 
and  ecchymosis  may  be  more  or  less  extensive  about  the  joint,  as 
indicated  by  Malgaigne,  Pitha,  and  others.  The  head  lies  in  front 
of  or  partly  beneath  the  neck  of  the  scapula,  covered  by  the  sub- 
scapularis or  embedded  in  its  torn  fibres  beneath  the  coracoid  process 
between  the  glenoid  cavity  and  the  thorax.  (Fig.  43.)  The  capsular 
rent  is  at  the  lower  front  margin  of   the   joint  between  the  subscapu- 


Subcoracoid 


t inn  of  the  shoulder,    (v.  Brims. 


DISLOCATIONS  OF  THE  Silo  I LI) Ell. 


63 


. 


laris  and  the  origin  of  the  long  head  of  the  triceps;  exceptionally  the 
capsule  is  torn  from  the  head  between  the  insertions  of  the  teres  minor 
and  subscapularis.  In  single  instances  dislocation  has  Keen  seen  with- 
out laceration  of  the  capsule.  The  position  of  the  head  and  limb 
is  determined  by  the  integrity  of  the  upper  front  part  of  the  capsule 
and  the  coracohumeral  ligament,  the  latter  being  stretched  tightly 
between  the  upper  margin  of   the 

cavity  and    the    lesser    tuberosity.  Fig.  43. 

For  this  reason  all  the  muscles  can 
be  severed  on  the  cadaver  without 
affecting  the  abnormal  fixation;  on 
dividing  the  still  intact  and  tense 
parts  of  the  capsule  the  elastic 
fixation  and  typical  position  of 
the  humerus  are  lost,  as  noted  by 
Busch.  The  long  biceps  tendon 
running  obliquely  from  the  top  of 
the  glenoid  cavity  to  the  upper 
arm  may  be  stretched  or  torn  or  be 
caught  around  the  neck  of  the 
humerus.  The  great  vessels  lie 
close  to  the  inner  surface  of  the 
dislocated  head.  The  violence  may 
not  only  tear  the  capsule,  but  also 
damage  the  adjacent  soft  parts  and 
bones.  The  muscles  reinforcing 
the  capsule  and  the  tendons  of  the 
subscapularis,  teres  minor,  supra- 
spinatusand  infraspinatus,  are  not 
infrequently  lacerated  or  torn  off 
with  a  lamina  of  bone.  The  fur- 
ther   the    head    advances   inward 

beneath  the  coracoid  process,  the  more  likely  is  the  greater  tuberosity 
to  be  torn  off.  Rarely  the  lesser  tuberosity  is  torn  off  by  the  sub- 
sea  pularis. 

Chipping  of  the  glenoid  margin  and  fracture  of  the  anatomical  or 
surgical  neck  are  fairly  frequent  complications  of  shoulder  dislocations. 
(Fig.  44.)  Fractures  of  the  neck  are  supposed  to  result  secondarily 
from  continuation  of  the  violence.  Thamhayn  collected  68  cases  of  this 
kind  (1868).  Fractures  of  the  acromion  or  coracoid  process  are  ex- 
ceptional. For  complications  of  the  great  vessels,  see  page  20.  Injuries 
of  the  adjacent  nerve-trunks,  especially  of  the  circumflex  nerve,  the 
motor  nerve  of  the  deltoid,  by  pressure  or  contusion  (rarely  lacera- 
tion) are  more  frequent  (page  24) ;  the  nerves  may  be  involved  second- 
arily in  the  constriction  produced  by  cicatrices  following  non-reduc- 
tion. Compound  dislocations  in  the  strict  sense  of  the  term  occur 
very  rarely  in  severe  accidents — dragging,  railway,  and  machinery 
accidents. 


Subcoracoid  dislocation.     (Anger.) 


64       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


Fig.  44. 

(  rraroifi 


Symptoms  and  Diagnosis  of  Forward  Dislocations. — The  deformity  of 
subcoracoid  dislocation  is  often  so  marked  as  to  be  recognizable  through 
the  clothing.  The  head  generally  inclines  to  the  affected  side;  the  arm  is 
abducted  to  about  20  degrees  from  the  chest-wall,  appears  lengthened, 
and  is  usually  supported  by  the  other  arm.  (Fig.  42.)  The  arch  of  the 
shoulder  is  more  angular  and  the  acromion  projects  sharply.  The  deltoid 
slopes  straight  from  the  acromion  or  sinks  in,  giving  an  indented  appear- 
ance to  the  arm  at  its  insertion.  Beneath  the  acromion  the  tissues  can 
be  pressed  into  the  hollow  of  the  glenoid  cavity.  The  axis  of  the  arm 
does  not  point  to  the  acromion,  but  to  Morenheim's  space,  where 
a  prominence   is  seen   and    felt,  recognizable  as  the    head,  especially 

on  rotating  the  arm.  The  abducted 
elbow,  in  the  pathognomonic  position  of 
"  elastic"  fixation,  cannot  be  adducted. 

Axillary  dislocation  differs  from  the 
above  in  the  lower  position  of  the  head, 
which  is  easily  felt  in  the  axilla;  the 
abduction,  indentation,  and  apparent 
lengthening  are  more  marked.  In  pre- 
scapular  dislocation  the  head  lies  further 
toward  the  median  line  than  in  the  sub- 
coracoid form  and  can  be  felt  in  the  axilla 
only  by  abducting  the  arm  strongly.  In 
infraclavicular  dislocation  the  outline  of 
the  head  is  visible  and  palpable  beneath 
the  clavicle  to  the  inner  side  of  the  cora- 
coid  process;  the  arm  is  so  adducted 
that  the  finger  can  hardly  be  forced  into 
the  axilla;  Bardenheuer,  however,  saw  2  cases  in  which  the  arm  was 
horizontal — "  horizontal  dislocation."  Complications  may  modify  the 
deformity;  with  fracture  of  the  neck  elastic  fixation  is  absent  and  the 
displaced  head  does  not  rotate  with  the  shaft;  crepitus  may  be  elicited 
by  passive  motion.  A  separated  tuberosity  can  sometimes  be  felt  in  the 
glenoid  cavity;  the  arm  admits  of  wider  motion  and  has  a  tendency  to 
become  "reluxated"  after  reduction. 

Of  less  diagnostic  importance  is  the  extravasation,  which  may  be 
entirely  absent  or  extend  to  the  fingers  and  to  the  crest  of  the  ilium. 
Exceptionally,  pressure  upon  the  veins  may  produce  stasis,  cyanosis, 
or  subsequently  oedema.  Numbness  and  tingling  in  the  fingers  from 
compression  of  the  nerves  are  reported  frequently;  for  the  symptoms  of 
severe  lesions  of  nerves  and  vessels,  see  the  respective  chapters. 

Supracoracoid  dislocation  is  an  atypical  form,  of  which  only  20  cases 
are  known  in  the  literature.  From  experiments  on  the  cadaver,  Busch 
regards  simultaneous  fracture  of  the  coracoid  as  essential  to  its  pro- 
duction. Mayo  Robson  saw  a  case  without  the  latter,  but  with  a 
longitudinal  fracture  of  the  tuberosity.  The  cause  was  commonly  an 
upward  blow  upon  the  abducted  elbow;  in  Busch's  case  it  was  violent 
upward  traction  upon  the  arm  and  a  simultaneous   blow  of    a    hoof 


Dislocation   of  head   of   the  humerus 
associated  with  fracture.    (Bryant.) 


DISLOCATlnys  OF  THE  SHOULDER.  65 

upon  the  shoulder.  Albert  reports  a  case  <>t*  bilateral  dislocation 
resulting  from  ;i  runaway  accident.  In  these  cases  the  deltoid  is  not 
indented;  the  arm  is  adducted  and  shortened;  mobility  is  slight  and 
possible  only  backward  and  forward.  The  empty  glenoid  cavity  is 
palpable  from  behind.  The  pathognomonic  sign  is  the  presence  of 
a  rounded  prominence  between  the  acromion  and  coracoid  process; 
it  pushes  up  the  deltoid  and  is  most  noticeable  on  drawing  the  arm 
backward.  Fracture  of  the  coracoid  may  he  recognizable  by  crepitus. 
For  reduction,  Bardenheuer  advises  backward  elevation  of  the  arm  and 
direct  pressure  upon  the  head. 

The  very  characteristic  symptoms  of  preglenoid  dislocation  make 
diagnosis  simple  in  recent  cases;  -welling  and  extravasation,  however, 
may  mask  the  angularity  of  the  shoulder  and  the  emptiness  of  the 
glenoid  cavity.  The  prominence  beneath  the  coracoid  may  be  slight, 
particularly  in  obese  individuals,  and  especially  if  the  head  lies  deeper 
in  the  subscapular  fossa;  it  can  then  be  felt  through  the  axilla  beneath 
the  pectorals.  In  doubtful  cases  and  for  the  determination  of  compli- 
cating bone  lesions  the  .r-ray  is  valuable. 

Prognosis. — In  uncomplicated  cases  with  proper  reduction  and  treat- 
ment the  prognosis  of  preglenoid  dislocations  is  favorable;  as  a  rule, 
full  use  of  the  arm  is  regained  in  from  four  to  eight  weeks,  especially 
in  children,  who  recover  rapidly  and  completely  if  active  motion  is 
begun  early;  in  old  individuals  a  certain  amount  of  stiffness  per- 
sists and  may  lessen  their  working  ability  from  25  to  50  per  cent. 
Exceptionally  the  dislocation  becomes  chronic.  Naturally  complica- 
tions modify  the  prognosis,  such  as  extensive  laceration  of  the  liga- 
ments or  capsule;  tear  fractures;  lesions  of  the  nerves  or  vessels, 
especially  stretching  or  rupture  of  the  circumflex  with  the  resulting 
paralysis  and  atrophy  of  the  deltoid.  To  prevent  a  delusive  prog- 
nosis Helferich  therefore  advises  electrical  test  of  the  deltoid  after 
reduction.  Forward  dislocations  are  rarely  irreducible  primarily;  the 
infraclavicular  form  is  an  exception,  and  in  spite  of  its  infrequeney 
several  cases  are  known  in  which  primary  operation — even  resection — 
was  necessary.  Primary  irreducibility  is  usually  due  to  complications. 
In  18  cases  Schoch  notes  as  causes:  stretched  capsule,  1;  fracture  of 
the  greater  tuberosity,  2;  fracture  of  the  neck,  12;  muscular  interposition, 
2;  cause  unknown,  1.  Kocher  found  fracture  of  the  tuberosity  in  5  of 
8  cases  operated  on;  Brims  found  the  same  in  several  instances.  If  for 
any  reason  reduction  fails,  "traumatic  reaction"  supervenes,  but  more 
slowly  than  after  reduction,  and  more  or  less  functional  disturbance 
persists.  The  latter  will  be  considered  later  under  old  shoulder  dislo- 
cations. 

Treatment  of  Forward  Dislocations. — The  intact  parts  of  the  capsule, 
which  are  put  on  the  stretch  at  the  moment  of  dislocation,  and  which 
hold  the  head  in  its  abnormal  position,  form  the  greatest  hindrance 
to  reduction.  The  anterior  fibres  of  the  coracohumeral  ligament  form  a 
tense  band  in  subcoracoid  dislocation  which  binds  the  head  against  the 
front  margin  of  the  cavity;  their  relaxation  is  therefore  essential  for 
Vol.  III.— .5 


QQ        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

reduction.  A  further  hindrance  is  produced  by  the  muscles  which  draw 
the  head  upward  and  inward;  naturally  they  have  to  be  considered, 
although  their  influence  varies  greatly  with  the  individual.  In  addition 
to  these  constant  factors  there  may  be  interposition  of  ruptured  portions 
of  the  capsule  or  tendons,  displacement  of  the  biceps  tendon,  or  perfora- 
tion of  the  subscapularis  by  the  head.  It  would  seem  that  many  authors 
underestimate  the  hindrance  caused  by  muscular  contraction  or  tension, 
possibly  in  view  of  Busch's  experiments  upon  the  cadaver.  Such 
experiments  indicate  only  the  mechanical  action  of  non-contractile 
tissues;  the  influence  of  muscular  tone  is  estimated  accurately  only  on 
living  subjects.  How  great  this  influence  is  seems  to  the  author  to  be 
demonstrated  by  the  fact  that  the  larger  number  of  dislocations  resisting 
reduction  are  easily  overcome  under  deep  anaesthesia. 

The  reduction  of  recent  dislocations  should  be  tried  first  without 
anaesthesia;  no  rule  can  be  laid  down  as  to  how  far  to  carry  the  attempt; 
in  the  absence  of  serious  general  counterindications  to  anaesthesia  dread 

Fig.  4.-, 


Kocher's  method  of  reduction  by  manipulation;  first  movement,  outward  rotation.     (Geppi.) 


of  the  latter  should  not  delay  reposition,  as  it  is  made  more  and  more 
difficult  by  the  increasing  infiltration  of  the  soft  parts.  Formerly  the 
various  methods  of  reduction  were  classified  as  reposition  by  impulsion; 
by  leverage;  by  rotation.  They  may  be  brought  into  two  groups,  accord- 
ing as  the  head  is  (1)  rotated  laterally  through  an  arc  (the  method  of 
Scninzinger,  Kocher,  and  Gordon);  or  (2)  simply  pushed  outward 
(Avicenna,  Cooper,  Konig,  and  others).  Of  the  first,  Kocher's  rotation- 
elevation  method  is  now  regarded  by  many  as  the  rational  one  for  sub- 
coracoid  dislocation,  as  it  takes  the  anatomical  relations  most  fully  into 
account  and  is  effected  without  great  force  or  pain.  The  steps  are  as  fol- 
lows: the  abducted  elbow  is  adducted  slowly  but  forcibly  against  the  body 
and  drawn  slightly  backward;  with  one  hand  on  the  elbow  and  the  other 
holding  the  wrist  of  the  semiflexed  arm,  the  upper  arm  is  rotated  outward 
slowly  but  forcibly  until  the  forearm  points  laterally  (Fig.  45);  with  the 


DISLOCATIONS  <>r  THE  SHOULDER. 


r>7 


arm  still  firmly  rotated  outward  the  elbow  is  raised  directly  Forward  as 
far  as  it  will  go  (Fig.  40);  in  this  position  the  forearm  is  swung  slowly 

inward  across  the  chest  to  the  other  side — that  is,  the  arm  is  rotated 


Fig.  4ti. 


Kocher's  method  of  reduction;  second  movement,  elevation  i>f  elbow.     (Ceppi.) 

inward,  and  reduction  usually  follows  with  a  snap.  (Fig.  47.)  By 
adduction  the  upper  part  of  the  capsule  is  put  on  the  stretch,  the  head 
is  thereby  pressed  against  the  joint-margin  and  forms  a  firm  point  of 

Fig.  47. 


Kocher's  method  of  reduction:  third  movement,  inward  rotation  and  lowering  of  elbow.    (Ceppi.) 


support  for  the  following  outward  rotation;  this  latter  opens  the  rent  in 
the  capsule;  by  elevation  the  intact  upper  part  of  the  capsule  and  coraco- 
humeral  ligament  are  relaxed,  the  lower  torn  portion  is  put  on  the 


68       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

stretch,  and  the  head  levered  into  the  cavity  outward  upon  the  fulcrum 
so  formed.  The  reduction  is  completed  without  force  by  simply  rotating 
the  arm  inward  and  lowering  it.  The  efficacy  of  Kocher's  method  is 
attested  by  Power,  who  in  129  cases  succeeded,  without  an  anaesthetic, 
98  times  in  the  first  attempt,  6  times  in  the  second,  8  times  in  the  third, 
failed  in  only  7 — a  total  of  113  without  anaesthetic,  6  with;  v.  Bergmann 
in  more  than  200  cases  had  no  failures.  There  are  instances,  however, 
in  which  Kocher's  method  fails,  and  in  which  Mothe's  or  Cooper's 
succeeds;  further,  it  has  caused  fracture  of  the  humerus  not  a  few 
times,  according  to  Kocher  himself  3  times  in  28  cases,  a  fact  easy 
to  understand  when  one  considers  the  enormous  leverage  of  the  semi- 
flexed forearm  during  rotation. 

In  Schinzinger's  method  the  operator  stands  in  front  of  the  patient, 
seizing  the  elbow  with  his  corresponding  hand  and  the  wrist  with  the 
other,  adducts  the  semiflexed  arm  firmly  against  the  chest  and  then 
rotates  outward,  an  assistant  meanwhile  holding  the  scapula;  the  assist- 
ant now  presses  both  thumbs  against  the  anterior  border  of  the  axilla 
and  so  holds  the  head  against  the  glenoid  margin,  while  the  operator 
completes  the  reduction  by  rotating  slowly  inward.  In  contrast  to 
Kocher's  method,  it  has  the  disadvantage  of  not  relaxing  the  upper 
part  of  the  capsule  and  the  coracohumeral  ligament. 

The  direct  impulsion  method  of  Avicenna  is  effectual  only  in  recent 
cases  presenting  slight  resistance;  the  shoulder  being  held,  the  arm  is 
slightly  abducted  and  the  operator  then  makes  direct  pressure  in  the  axilla 
upon  the  head  with  the  fingers  of  the  corresponding  hand,  or  with  the 
thumbs,  with  counterpressure  upon  the  acromion.  Konig  recommends 
Mothe's  old  hyperabduction  method:  the  shoulder  is  drawn  firmly  back- 
ward and  downward,  the  body  toward  the  other  side,  by  two  cloth  bands, 
one  passed  over  the  shoulder  and  the  other  around  the  chest  from  the 
other  side;  the  arm  is  then  abducted  and  elevated  slowly  and  steadily 
while  an  assistant  presses  the  head  directly  toward  the  socket;  this  is 
followed  by  quick  adduction  and  inward  rotation  of  the  semiflexed  arm. 

Cooper's  lever  method  aims  to  produce  a  fulcrum  in  the  axilla:  the 
patient  lies  upon  the  floor,  the  operator's  foot  is  placed  in  the  axilla  and 
direct  traction  is  made  on  the  arm;  or  the  operator  stands  upon  a  stool, 
places  his  knee  against  the  axilla  from  behind,  fixes  the  shoulder  with 
one  hand,  and  makes  direct  downward  traction  upon  the  arm.  The 
method  is  effectual,  but  is  painful  and  liable  to  lacerate  the  vessels  and 
nerves,  an  accident  to  be  avoided,  especially  in  old  individuals.  Occa- 
sionally it  has  proved  indispensable,  and  may  be  tried,  possibly  with 
appropriate  rotation,  in  cases  in  which  Kocher's  rotation  fails. 

Bruns  combines  Mothe's  method  with  gentle  leverage  by  adducting 
the  arm  against  the  fist  held  in  the  axilla.  With  Konig,  the  author  has 
every  reason  to  be  satisfied  with  the  results  of  this  method. 

Riedel  has  recently  suggested  a  method  which  he  tested  in  about  150 
cases:  the  arm  is  drawn  with  a  forcible  jerk  toward  the  other  side  of 
the  pelvis,  the  muscles  being  completely  relaxed  under  deep  anaesthesia. 

Instead  of  using  anaesthesia,  Stimson  overcomes  the  muscular  resist- 


DISLOCATIONS  OF  THE  SHOULDER. 


69 


ance  by  continuous  weight-extension;  the  dislocated  arm  is  lowered 
through  an  opening  cut  In  a  canvas  coi  and  a  weight  attached.  (Fig.  48.) 
Hofmeister  modifies  this  method  by  placing  the  patient  on  the  sound 
aide  and  suspending  the  arm  vertically  by  means  of  a  pulley,  weight, 

and  continuous  traction.  The  author  has  had  such  successful  results 
with  Stimson's  method  that  he  employs  it  regularly.  It  is  particularly 
useful  for  the  practising  surgeon  in  dispensing  with  a  trained  assistant 
and  obviating  the  danger  of  further  injury.  A  cloth  loop  is  bound 
tightly  along  the  entire  arm  and  then  weighted  with  10  pounds,  10 
pounds  being  added  at  intervals  of  from  one  to  two  minutes  up  to  40 
pounds;  in  from  five  to  fifteen  minutes  the  head  advances  outward  to 
the  level  of  the  cavity  and  either  slips  in  itself  or  is  easily  forced  in  by 

Fig.  48. 


Reduction  of  anterior  dislocation  of  the  shoulder.     (Stimson.) 

seizing  the  wrist  and  adducting  the  arm  against  the  fist  held  in  the  axilla. 
In  30  dislocations  remaining  unreduced  up  to  the  fourteenth  day  anaes- 
thesia was  required  to  relax  the  muscles  in  only  3  of  the  cases  reduced  by 
this  method  in  spite  of  the  fact  that  previously  many  futile  attempts  had 
been  made,  chiefly  in  the  same  direction,  with  and  without  anaesthesia. 
The  method  differs  from  the  old  traction  methods  in  requiring  less  force. 
Recently  Roloff  reduced  several  cases  by  gradual  manual  traction. 

With  the  exception  of  the  methods  of  Schinzinger  and  Kocher,  which 
are  specially  adapted  for  subcoracoid  dislocation,  all  of  the  above 
methods  are  applicable  to  forward  dislocations,  certain  modifications 
being  advisable  according  to  the  position  of  the  head.     For  example, 


70       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


\ 


in  infraclavicular  dislocation  Konig  advises  backward  traction  upon  the 
arm  and  counterpressure  against  the  scapula.  For  this  form  Kocher 
recommends  that  his  rotation  method  should  be  tried  first,  with  the 
elbow  pushed  backward  in  order  to  give  the  head  a  firm  point  of  support 
against  the  axillary  border  of  the  scapula.  For  axillary  dislocation  he 
employs  Mothe's  method,  in  addition  rotating  the  abducted  arm  outward. 
Traction  by  weight  is  useful  for  all  dislocations  of  the  shoulder,  even 
the  posterior  varieties.  The  line  of  traction  is  varied  by  moving  the 
patient  in  the  appropriate  direction  beneath  the  pulley.     As  the  head 

often  slips  back  gradually  into 
Vm.  49.  the  cavity  without  a  snap,  re- 

duction should  always  be  veri- 
fied by  the  absence  of  deform- 
ity, the  ability  to  adduct  the 
arm  and  place  the  hand  upon 
the  other  shoulder,  and  by  the 
absence  of  elastic  resistance. 

An  irreducible  dislocation 
demands  immediate  operation 
as  the  latter  is  easier  and  more 
successful  if  not  delayed;  resec- 
tion should  be  considered  only 
as  a  last  resort. 

Subsequent  treatment  con- 
sists  in  immobilizing  the  arm 
in  a  sling  or  a  Velpeau  dress- 
ing. Massage  and  gentle  pas- 
sive motion  are  begun  at  the 
end  of  eight  days.  Abduction 
should  be  avoided  at  first.  This 
period  of  rest  of  eight  days  is 
sufficient  to  determine  the  functional  result.  For  this  reason  Thiem 
recommends  that  motion  and  massage  should  begin  in  uncomplicated 
cases  immediately  after  reduction,  and  should  be  repeated  as  often 
as  possible  daily.  In  the  first  few  days  the  joint  is  compressed  with 
the  hands  during  motion.  For  many  years  the  author  has  followed 
Thiem's  principles  in  the  after-treatment  of  simple  dislocation  of  the 
shoulder,  and  so  far  has  never  seen  reluxation  or  habitual  dislocation 
follow;  on  the  contrary,  the  usefulness  of  the  joint  was  often  regained  at 
an  early  period,  whereas  in  the  author's  previous  experience  more  or 
lfj--  pronounced  stiffness  was  always  to  be  feared. 

The  complications  mentioned  demand  appropriate  measures.  Deltoid 
paralysis  requires  early  electrical  treatment.  Even  compound  disloca- 
tions of  the  shoulder  can  recover  without  much  functional  disturbance, 
as  shown  by  Nussbaum,  Soderbaum,  and  others.  Strict  antisepsis  and 
the  reduction  of  the  head  if  possible  are  the  requisites.  Severe  com- 
minution, extensive  avulsion  of  the  muscular  attachments,  or  drying 
up  of  the  cartilage  requires  resection,  the  results  of  which,  according 


Subeoraeoid  dislocation   with  fracture  of    the    neck. 
Reversed  head  adherent  to  the  9capula.    (v.  Brans.) 


DISLOCATIONS  OF  THE  SHOULDER.  71 

to  Uhde,  arc  good.     Simultaneous  fracture  of  the  neck  calls  first  for 

the  reduction  of  the  head  by  direct  pressure  and,  the  author  would 
suggest,  with  the  aid  of  traction  by  weight.  Thamhayn  was  successful 
in  22  of  68  cases.  If  reduction  is  not  possible,  operation  with  or  without 
suture  of  the  fragments  is  the  ideal  procedure;  Schoch  reports  10  excellent 
results,  1  fair  result,  and  1  requiring  later  resection  among  12  cases. 
If  reduction  by  operation  is  not  possible,  the  head  should  be  removed. 
If  operation  is  counterindicated  by  age  or  general  condition  or  is  refused, 
Cooper  recommends  placing  the  end  of  the  shaft  in  the  glenoid  cavity 
and  encouraging  the  formation  of  a  new  joint  by  early  motion.  The 
head  can  he  removed  later  if  it  produces  disturbance.  The  attempt  to 
reduce  the  dislocation  after  waiting  from  six  to  ten  weeks  for  the  fracture 
to  heal  can  hardly  have  many  advocates  at  the  present  time. 

Backward  Dislocation  of  the  Shoulder. 

This  form  of  dislocation  is  rare.  In  207  dislocations  of  the  humerus 
>een  by  Kronlein  in  Langenbeck's  clinic  there  was  only  one  of  this  sort. 
Finckh  in  v.  Brims'  clinic  saw  201  dislocations  forward  and  only  5 
backward.     Busch  saw  a  case  in  a  child  of  ten  years. 

Subacromial  dislocation  signifies  that  the  head  lies  above  and  behind 
the  joint  beneath  the.  acromion  upon  the  neck  of  the  scapula;  if  it  lies 
further  down  in  the  infraspinate  fossa  beneath  the  spine  of  the  scapula, 
the  dislocation  is  called  infraspinate.  The  latter  form  is  even  more 
rare.  Retroglenoid  dislocation  is  generally  the  result  of  a  blow  upon 
the  shoulder  from  in  front;  indirectly  it  is  produced  by  a  fall  upon 
the  outstretched  hand  or  upon  the  elbow  held  forward;  also  sudden 
forcible  elevation  of  the  elbow  or  forced  muscular  action,  as  in  throw- 
ing or  in  epileptic  attacks.  According  to  Malgaigne,  8  of  29  cases  of 
retroglenoid  dislocation  were  caused  by  convulsions.  Considerable 
force  is  required  to  produce  this  variety,  as  the  capsule  is  reinforced  by 
the  outward  rotators  at  the  point  where  the  head  perforates.  Engel's 
experiments  on  the  cadaver  show  that  it  occurs  only  after  the  insertion 
of  the  subscapularis  on  the  lesser  tuberosity  is  torn  off  and  a  rent  is 
made  in  the  capsule  close  to  the  posterior  margin  of  the  cavity. 

Infraspinate  Dislocation. — For  the  production  of  this  form  it  is 
necessary  that  the  arm  should  be  flexed  sharply  and  that  a  blow  strike 
the  elbow  as  it  is  held  fonvard,  or  that  the  arm  be  rotated  forcibly  inward, 
as  in  falling  forward  upon  the  elbow.  The  capsular  tear  is  in  the  lower 
posterior  quadrant,  the  greater  part  of  the  posterior  circumference 
remaining  intact  and  by  its  tension  preventing  ascent  of  the  head. 
The  head  lies  in  the  infraspinate  fossa  pointing  backward  and  inward; 
the  lesser  tuberosity  is  pressed  firmly  against  the  glenoid  margin  and 
held  there  chiefly  by  the  posterior  portion  of  the  coracohumeral  ligament; 
the  cavity  is  covered  by  the  anterior  wall  of  the  capsule. 

Symptoms. — The  shoulder  is  broadened,  the  arm  abducted  and 
directed  somewhat  forward,  and  rotated  inward.  Beneath  the  acromion 
there  is  usually  a  distinct  depression  and  in  front  of  the  joint  a  pit  which 


72        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


appears  to  be  divided  into  a  larger  outer  and  a  -mailer  inner  half  by  a 
band  running  from  the  coracoid  process  to  the  arm.  (Busch.)  The 
head  is  usually  recognizable  as  a  rounded  prominence  in  the  infra- 
spinate  fossa,  especially  by  rotating  and  moving  the  arm. 

Diagnosis.— The  diagnosis  is  not  difficult.  The  axis  of  the  humerus 
points  to  the  outer  side  of  and  behind  the  cavity,  particularly  as  seen 
from  the  side.       Fig.  51 . 

Prognosis.— The  prognosis  is  favorable.  Reduction  is  almost  always 
easy  even  after  months;  in  a  case  of  Sedillot's  at  the  end  of  a  year.  On 
the  other  hand,  recurrence  is  not  infrequent,  habitual  dislocation  being 
often  seen  as  the  result  of  backward  dislocation.  To  reduce  infraspinate 
dislocation,  Kocher  recommends:  1.  To  increase  the  inward  rotation  of 
the  upper  arm  in  the  existing  position  of  flexion  in  order  to  force  outward 


Fig.  50. 


Fig.  51. 


Posterior  dislocation  (subacromial,  subspinate). 

the  head  held  by  the  stretched  capsule,  analogous  to  outward  rotation 
in  subcoracoid  dislocation.  2.  Abduction  to  relax  the  coracohumeral 
ligament  and  free  the  head  from  the  posterior  margin  of  the  cavity. 
3.  Traction  to  put  the  lower  part  of  the  capsule  on  the  stretch.  4.  Out- 
ward rotation  to  complete  the  reduction,  after  which  the  arm  is  adducted. 
Reduction  is  sometimes  easy  by  abducting  the  arm  to  a  horizontal  with 
traction,  then  rotating  outward  and  adducting  with  direct  pressure  upon 
the  head. 

Subacromial  Dislocation.— Although  by  no  means  frequent,  this 
variety  is  more  common  than  infraspinate  dislocation,  and  is  produced 
by  a  fall  upon  the  front  of  the  shoulder  or  a  blow  in  the  opposite  direc- 
tion. The  head  is  not  displaced  so  far,  especially  to  the  inner  side,  as 
in  the  preceding  form.  The  anatomical  neck  lies  upon  the  glenoid 
margin;  the  anterior  fibres  of  the  coracohumeral  ligament  are  tense. 
The  lesser  tuberosity  is  often  torn  off  by  the  tendon  of  the  subscapularis. 
Reduction  is  usually  easv.     Forced   abduction   or   flexion  is   liable   to 


DISLOCA  TIONS  OF  THE  SH0ULD1  7;} 

overstretch  the  lower  part  of  the  capsule.  Simple  traction  in  the  given 
direction  is  often  sufficient,  and  the  only  part  of  the  capsule  on  the 
stretch  is  relaxed  by  inward  rotation.  Koelier  recommends  1  I  forcible 
inward  rotation  in  the  given  flexion  position  of  the  arm;    2)  traction  in 

the  same  given  direction  of  the  arm,  then  outward  rotation  and  exten- 
sion. In  one  instance  Malgaigne  was  unable  to  effect  reduction  until 
the  elbow  had  Ween  drawn  backward.     In  view  of  the  author's  succ<    - 

with  weight-extension  in  forward  dislocations  it  should  be  tried  here. 

Old  Dislocations  of  the  Shoulder. 

Old  dislocations  are  observed  most  frequently  in  the  shoulder,  and 
chiefly  the  forward  variety — 98  per  cent.,  according  to  Smital  and 
Finckh.  Old  bilateral  dislocations  have  also  been  reported.  (Lister, 
James.)  Although  it  is  true  that  the  majority  of  old  dislocations  of  the 
shoulder  are  due  to  the  indolence  of  the  patient,  who  uses  household 
remedies  or  is  satisfied  with  the  advice  of  a  charlatan,  still,  in  view  of 
the  material  coming  under  our  observation,  it  would  not  be  proper  to 
suppress  the  fact  that  a  lamentable  percentage  is  referable  to  surgical 
neglect,  perhaps  as  the  result  of  an  uncertain  diagnosis  due  to  marked 
swelling,  perhaps  faulty  technic,  inadequate  assistance,  or  improper 
anaesthesia,  all  of  which  happens  not  infrequently,  and  although  it  is 
far  from  the  author's  purpose  to  criticise  the  attending  surgeon,  never- 
theless it  must  be  regarded  as  an  error  to  content  one's  self  and  the 
patient  with  the  assurance  that  nothing  further  can  be  done  until  the 
traumatic  reaction  has  subsided,  instead  of  consulting  a  more  expe- 
rienced colleague  or  sending  the  patient  to  a  hospital. 

When  is  a  dislocation  old?  It  is  hardly  possible  to  give  a  certain 
time.  Still,  in  general  a  dislocation  may  be  regarded  as  old  after  from 
four  to  six  weeks,  as  at  that  time  all  reaction  has  disappeared  in  the 
injured  area. 

Anatomy. — Following  resorption  of  the  extravasated  blood  and  the 
disappearance  of  swelling,  more  or  less  connective  tissue  forms  about 
the  dislocated  head  like  a  new  capsule  and  soon  entirely  covers  the  tear 
in  the  old  capsule.  There  are  irregularities  in  the  atrophying  cartilage 
of  the  head  and  irregular  bony  growths  if  the  muscular  attachments 
have  been  torn  off.  The  anterior  glenoid  margin  may  be  indented  where 
it  presses  against  the  head.  At  the  point  where  the  head  rubs  against 
the  scapula  the  irritation  of  the  periosteum  is  followed  by  thickening 
and  the  formation  of  new  cavity,  whereas  the  old  cavity  disappears  and 
is  levelled  off  like  the  alveolus  after  extraction  of  a  tooth;  it  may  even 
become  convex.  (Fig.  52.)  Long  before  this  event  the  old  capsule  has 
contracted  concentrically  over  the  empty  cavity  until  it  lies  as  a  fibrous 
mass  upon  the  joint-surface  and  becomes  adherent,  so  that  even  at  a 
period  when  the  form  of  the  cavity  is  still  normal  it  may  completely  pre- 
vent reduction.  The  cartilage  meanwhile  mav  remain  unchanged  for 
months.  The  new  capsular  space  communicates  with  the  old  one 
through  a  more  or  less  narrowed  opening,  or  may  be  separated  from 


74       MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 


it  entirely  if  the  head  is  greatly  displaced.  Laminated  growths  of 
bone  are  sometimes  produced  by  ossification  of  the  connective  tissue 
extending   from    the  coracoid    process  or   the  head,  or  the   ossification 

may  be  limited  to  single  ligaments.     The  oc- 
Fig.  52.  casional  adhesion  which   takes  place  between 

the  vessels  and  the  dislocated  head  has  been 
mentioned.  Kocher  saw  a  case  in  which  the 
circumflex  and  axillary  arteries  were  adherent 
to  the  wall  of  the  newly  formed  cavity.  The 
muscles  running  from  the  thorax  and  scapula 
to  the  dislocated  head  are  correspondingly 
shortened. 

Symptoms  and  Diagnosis. — The  degree  of 
mobility  of  the  head  in  its  new  position, 
namely,  whether  there  is  ankylosis  or  a 
nearthrosis,  depends  chiefly  upon  whether  the 
arm  is  moved  from  the  outset  or  not.  The 
degree  of  functional  impairment  varies  in  like 
manner.  Every  surgeon  in  active  practice  has 
seen  cases  in  which  the  impairment  was 
slight;  still,  Pitha's  statement  that  "an  unre- 
duced dislocation  of  the  shoulder  usually 
produces  a  lasting  and  very  sad  deformity  of 
the  extremity,  and  compromises  the  earning 
ability  of  those  dependent  upon  hand  work," 
applies  to  the  majority  of  cases.  Abduction  is  usually  limited  in  spite  of 
the  compensatory  mobility  of  the  scapula. 

The  diagnosis,  in  contrast  to  recent  cases,  is  aided  by  the  absence 
of  swelling.  Abnormal  mobility  cannot  occasion  confusion.  Sometimes 
the  radiograph  gives  important  details  as  to  treatment,  less  so  as  to  the 
diagnosis. 

Prognosis. — The  prognosis  as  far  as  it  concerns  reduction  depends 
upon  the  time  that  has  elapsed  and  the  anatomical  conditions  in  the 
individual  case.  According  to  Finckh's  statistics  from  v.  Bruns'  clinic, 
reposition  in  uncomplicated  cases  is  always  possible  up  to  the  fourth 
week;  from  the  third  to  the  ninth  week  successful  in  about  77  per  cent, 
of  the  cases,  and  impossible  after  fourteen  weeks.  Further  than  this  it  is 
not  possible  to  determine  the  period  of  reducibility;  in  individual  instances 
reduction  was  effected  after  months;  Simon  was  successful  after  twenty- 
one  months.  The  irregular  dislocations  generally  become  firmly 
adherent  and  irreducible  at  an  earlier  period;  many  of  the  dislocations 
to  the  inner  side  of  the  coracoid  process  were  irreducible  after  a  few 
weeks.  Old  dislocations  have  acquired  an  evil  reputation  on  account  of 
the  accidents  resulting  from  forcible  attempts  at  reduction,  particularly 
injuries  of  the  large  vessels  and  nerves  and  fracture  of  the  humerus. 
Flaubert  found  in  1  case  that  the  last  four  trunks  of  the  brachial  plexus 
had  been  torn  completely  from  the  spinal  cord;  the  patient  died  eighteen 
days  after  reduction.     For  injuries  of  the  vessels  compare  page  20. 


Newly  forme*)  cavity  below 
the  coracoid  process  in  an  old 
dislocation,     (v.  Bruns.) 


DISLOCATIONS  OF  THE  SHOULD EB.  75 

Treatment. — The  treatment  of  old  dislocations  requires  great  care 
and  individualization.     If  possible,  ;i  skiagram  should  be  obtained  to 

determine  t In*  existence  of  exostoses,  splinters,  etc.,  which  under  circum- 
stances can  damage  the  vessels  during  reduction.  Naturally  reduction 
should  be  attempted  only  when  there  is  a  prospect  of  benefit.  The 
older  the  dislocation  and  the  freer  the  mobility,  the  less  indication  there 
is  for  interference.  The  age  and  general  condition  of  the  patient,  par- 
ticularly with  regard  to  the  possibility  of  secondary  injuries,  are  to  he 
considered;  and  finally  in  accident  cases  arises  the  question  as  to  whether, 
considering  the  mental  attitude  of  the  patient,  the  surgeon  can  expect 
that  the  latter  will  give  the  aid  in  the  mechanical  treatment  necessary 
to  obtain  better  function  than  already  exists,  for  if  ankylosis  follows 
reposition  the  surgeon  might  as  well  have  saved  himself  the  trouble. 

All  the  methods  described  in  the  treatment  of  recent  dislocations, 
except  those  of  direct  pressure,  are  applicable;  but  from  the  nature  of 
the  case  greater  force  is  usually  required  and  anaesthesia  is  almost  indis- 
pensable. The  first  step  is  the  mobilization  of  the  head  by  stretching 
and  breaking  up  the  adhesions.  This  is  accomplished  by  the  rotation 
methods,  which  are  also  valuable,  according  to  Kocher,  Ceppi,  and 
Korte,  for  the  reduction.  Forcible  traction  by  Simon's  "Pendel- 
methode"  or  weight-traction  often  give  good  results  where  other  methods 
fail.  Violent  traction  with  block  and  tackle  or  similar  apparatus  is 
abandoned,  at  least  in  Germany,  on  account  of  the  danger  of  lacerating 
the  skin,  vessels,  and  nerves,  and  even  of  tearing  the  arm  out  or  off. 

Reduction  by  operation,  or  resection,  is  indicated  if  the  above  methods 
fail.  The  indication  varies  according  to  age,  social  position,  the  duration 
of  the  dislocation,  or  an  already  formed  nearthrosis,  and  is  absolute  if 
there  are  symptoms  of  pressure  upon  the  nerves  or  vessels.  Subcuta- 
neous division  of  the  soft  parts  and  adhesions,  as  employed  previously 
by  Dieffenbach  and  others,  and  recently  recommended  by  Polaillon  and 
Molliere,  finds  few  advocates  at  the  present  time.  Whereas  at  an  earlier 
period,  of  the  two  above  methods  resection  alone  could  be  considered, 
and  even  until  within  a  few  years  the  majority  of  surgeons  employed 
arthrotomy  only  for  the  rather  recent  dislocations,  the  advance  in  asepsis 
has  prepared  a  new  field,  even  in  old  cases,  so  that  the  author  feels 
justified  in  attempting  reduction  by  operation  first  and  resecting  later 
if  the  necessity  is  indicated  in  the  course  of  operation.  Schoch,  to  whom 
we  are  indebted  for  the  most  recent  exposition  of  the  question, 
advises  resection  if  the  head  has  to  be  damaged  in  the  operation  or  if 
the  cavity  is  too  shallow.  In  the  latter  case  v.  Bergmann  sutures  the 
anterior  portion  of  the  capsule  to  the  biceps  tendon  to  obtain  the  neces- 
sary stability.  Secondary  resection  may  be  required  if  infection  or 
necrosis  of  the  head  results  from  operation.  The  statistics  of  operative 
reduction  given  by  Schoch  show  that  the  failures  constitute  about  19 
per  cent,  and  the  successes  65  per  cent.  The  most  frequent  cause  of 
primary  irreducibility  was  simultaneous  fracture;  in  old  cases  it  w-as 
hindrance  produced  by  the  capsule.  The  other  complications,  aside 
from  those  produced  by  the  capsule,  wTere  fracture  of  the  greater  tuber- 


76        MALFORMATIONS  AND  INJURIES  OF  THE  SHOULDER. 

osity,  lesser  tuberosity,  neck,  acromion,  or  acetabulum,  and  interposition 
of  the  muscles. 

The  incision  generally  used  to  expose  the  head  is  made  along  the 
anterior  border  of  the  deltoid,  avoiding  the  circumflex  nerve.  An  axillary 
incision  is  occasionally  advisable.  The  subsequent  procedure  depends 
upon  the  condition.  In  view  of  the  present  knowledge  of  the  conditions 
preventing  redaction,  it  is  of  great  importance  in  old  cases  to  remove 
all  shrunken  and  adherent  portions  of  the  capsule  from  the  glenoid 
cavity  after  the  head  has  been  exposed  and  freed  sufficiently  to  give 
access  to  the  articular  surface.  Pronounced  shortening  of  the  muscles 
may  necessitate  division.  On  account  of  the  nature  of  the  wound, 
drainage  is  advisable.  A  good  result  presupposes  primary  union,  early 
motion,  massage,  and  electricity.  If  resection  is  necessary,  it  should  be 
as  limited  as  possible. 

Habitual  Dislocation  of  the  Shoulder. 

By  relapsing  dislocation  is  understood  a  recurrence  directly  following 
reduction,  usually  caused  by  imprudent  abduction  or  paralysis  of  the 
muscles.  (Arloing.)  By  habitual  dislocation  is  understood  a  condition  of 
insufficient  stability  of  the  joint  allowing  dislocation  on  slight  provo- 
cation. Where  the  condition  is  present  the  dislocation  happens  fre- 
quently and  often  from  very  slight  cause,  as  in  lifting  the  arm  to  arrange 
the  hair,  in  writing,  in  slipping  the  arm  into  a  sleeve,  in  taking  out  a 
pocket  handkerchief,  in  mounting  a  horse,  etc.  Cases  are  reported  in 
which  the  dislocation  has  occurred  50  or  100  times.  Habitual  disloca- 
tion has  been  seen  both  of  the  forward  and  backward  variety;  accord- 
ing to  many  observers,  dislocations  backward  show  the  greater  tendency 
to  become  habitual. 

The  pathogenesis  has  been  studied  more  carefully  since  operative 
treatment  has  made  inspection  of  the  joint  possible  during  life.  Jossel 
has  reported  the  anatomical  findings  in  detail.  The  capsule  is  usually 
abnormally  dilated  and  relaxed.  Exceptionally  its  insertion  at  the  inner 
margin  of  the  joint  is  interrupted  and  the  joint  communicates  with  the 
subscapular  bursa.  In  several  instances  the  rotators  or  the  greater 
tuberosity  were  torn  off,  with  the  result  that  the  concentric  stability  of 
the  articular  surfaces  was  lessened  during  motion.  In  quite  a  few  of  the 
cases  there  was  a  typical  groove  on  the  posterior  surface  of  the  head  to 
the  inner  side  of  the  greater  tuberosity,  regarded  by  most  authors  as  the 
result  of  avulsion,  of  osteochondritis  dissecans,  or  of  trition.  Sometimes 
a  small  fragment  broken  off  could  be  demonstrated.  On  the  glenoid 
surface  there  are  often  marked  changes;  the  margin  was  defective  in 
several  instances,  usually  the  inner  part  corresponding  to  the  greater 
frequency  of  subcoracoid  dislocations.  Burrell  and  Lovett  noted  atrophy 
of  certain  muscles;  in  a  number  of  cases  they  found  the  coracobrachialis, 
triceps,  deltoid,  supraspinatus  and  infraspinatus,  rhomboid,  levator 
anguli  scapula?,  and  latissimus  dorsi  greatly  atrophied  and  relaxed — in 
one  case  one  week  after  the  accident.     Schrader  calls  attention  to  the 


DISLOGA  TIONS  OF  THE  SHOULDER.  77 

habitual  dislocation  developing  in  syringomyelia,  having  seen  2  such 
cases  in  v.  Brims'  clinic.  It  is  sometimes  of  a  grade  that  is  never  seen 
in  traumatic  cases. 

Treatment. — Bandaging  is  usually  ineffectual.  The  functional  result 
of  operation  is  not  always  certain,  although  recurrence  is  always  pre- 
vented. The  old  methods  aiming  to  product'  cicatricial  contraction  of 
the  capsule  have  been  abandoned.  The  injection  of  iodoform  or  tincture 
of  iodine  has  been  successful.  Of  the  non-operative  measures,  the  only 
ones  to  be  considered  are  the  continued  immobilization  of  the  joint  for 
months  in  a  position  preventing  dislocation  or  the  wearing  of  protective 
apparatus,  both  of  which  are  often  unavailing.  Weil  recommended  a 
padded  broad  leather  girdle  binding  the  shoulder  and  fitted  with  an 
axillary  pad. 

Operation  is  the  proper  treatment  of  habitual  dislocation.  At  first 
resection  was  done  according  to  Kilter's  instructions,  and  by  the  methods 
of  Kramer,  Kiister,  Volkmann,  Lobker,  and  Kraske;  the  present  opera- 
tive methods  aim  to  restore  the  stability  of  the  head  by  narrowing  the 
relaxed  capsule.  Ricard  uses  the  purse-string  suture  and  immobilizes 
for  seven  weeks.  Steinthal  reefs  the  dilated  capsule  with  silkworm-gut 
without  opening  it.  Most  surgeons  open  the  capsule.  Gerster,  Burrell, 
and  Lovett  excise  portions  of  the  front  of  the  capsule  and  suture.  Miku- 
licz divided  the  capsule  longitudinally  in  one  instance,  and  sutured  the 
inner  flap  over  the  outer  at  the  weakest  point  with  four  silver-wire 
sutures.  W.  Miiller  performed  3  such  conservative  operations,  and 
regards  resection  as  necessary  only  in  extreme  cases.  He  recommends 
opening  the  joint,  removing  any  free  or  pedunculated  bodies,  resecting 
the  capsule,  suturing  any  torn  rotators,  and  immobilizing  for  at  least 
fourteen  days  with  tamponage  and  drainage,  in  order  to  obtain  the 
greatest  possible  retraction  of  the  soft  parts;  he  recommends  exposure 
and  suturing  in  folds  in  appropriate  cases. 


CHAPTER   II. 

DISEASES  OF  THE  SHOULDER. 
DISEASES  OF  THE  BURS^J  OF  THE  SHOULDER. 

Diseases  of  the  bursa?  are  not  always  easily  differentiated  from 
affections  of  the  joint.  The  following  bursa?  will  be  considered:  the 
acromial,  subcoracoid,  subscapular,  subserrate,  and  more  particularly 
the  subdeltoid  and  the  subacromial  frequently  communicating  with  it. 

Diseases  of  the  Acromial  Bursa. — Chronic  inflammation  and  hy- 
groma result  from  occupational  injuries  in  people  accustomed  to  carry 
loads  upon  the  shoulder.  A  round  elastic  swelling  forms  on  the  shoulder, 
movable  beneath  the  skin;  it  is  hemispherical,  its  surface  smooth  and 
unlobulated  in  contrast  to  lipoma.  Such  hygromata,  as  they  produce 
real  discomfort  and  functional  disturbance,  require  excision;  the  opera- 
tion is  not  difficult.  Exceptionally,  as  noted  by  Vogt,  the  bursa  is 
enlarged  by  arthritic  deposits;  acute  suppurative  bursitis  may  supervene 
upon  hygroma  after  trauma  and  require  incision  and  drainage. 

Diseases  of  the  Subdeltoid  Bursa,. — The  subdeltoid  bursa  is  protected 
to  a  certain  extent  against  direct  violence  by  the  thick  covering  of  the 
deltoid,  but  acute  and  chronic  inflammations  are  not  infrequent,  and 
may  present  difficulties  in  the  diagnosis.  The  rare  traumatic  hygroma 
is  regarded  as  the  result  of  hematoma.  Acute  suppurative  bursitis  has 
been  seen  following  pneumonia  and  pyaemia.  Jarjavav  calls  attention 
to  the  fact  that  acute  bursitis  has  been  diagnosticated  as  displacement 
of  the  biceps  tendon,  and  explains  the  error  by  the  involvement  of  the 
tendon  sheath  of  the  biceps,  which  produces  the  functional  disturbance 
of  the  muscle. 

Under  the  name  of  periarthritis  humeroscapularis  Duplay  describes 
a  chronic  adhesive  inflammation  of  the  subdeltoid  bursa;  it  results  from 
direct  or  indirect  injury  and  produces  complete  obliteration  of  the  sac. 
In  Germany  Colley  has  recently  considered  this  form  of  disease  in  a 
study  of  41  cases,  mostly  in  Kuster's  clinic,  and  believes  that  this  process 
plays  a  much  more  important  part  than  was  formerly  supposed,  com- 
pared to  the  interarticular  changes,  in  the  production  of  stiff  shoulder. 
He  claims  that  the  disease  is  not  infrequent,  but  is  usually  mistaken  for 
a  joint-affection.  The  important  points  in  differential  diagnosis  are  the 
loss  of  abduction  if  the  scapula  is  fixed,  the  existence  of  mobility  in  the 
sagittal  plane  and  of  rotation  about  the  long  axis,  whereas  in  inflam- 
mation of  the  joint  all  motion  is  painful;  in  Duplay's  case  the  scapula 
followed  all  movements.  In  many  instances  at  the  onset  there  is  sharp 
pain  radiating  down  the  arm  and  preventing  sleep.  Tenderness  is  limited 
to  the  area  of  the  bursa;  that  part  of  the  joint  felt  in  the  axilla  is  not 
(78) 


DISEASES  OF  THE  l'.rilSJE  OF  THE  SHOULDER. 


79 


Fig.  53. 


tender.  The  treatment  consists  in  breaking  up  the  adhesions  under 
anaesthesia;  later,  massage,  passive  motion,  the  faradic  current,  and 
baths  should  be  continued  until  tenderness  has  disappeared  and  active 
motion  is  free. 

Rice-body  hygroma,  a  tuberculous  bursitis,  has  been  recently  described 
by  Blauel  in  a  review  of  16  cases  following  his  observation  of  a  typical 
case  in  v.  Bruns'  clinic.  The  disease  is  common  to  all  ages  except  the 
first  ten  years  and  is  more  frequent  in  men  than  in  women;  it  always 
produces  considerable  enlargement  of  the  bursa  even  to  the  size  of  half 
an  orange  or  of  a  child's  head,  as  in  Blauel's  and  Stanley's  cases,  and 
so  may  be  mistaken  for  a  soft  sarcoma 
or,  as  reported  by  Ehrhart,  for  lipoma. 
The  bursa  contains  characteristic  fibrin 
clots  in  the  form  of  rice-bodies  or 
"melon  seeds"  free  or  pedunculated 
in  clear  or  turbid  serous  fluid.  The 
process  may  advance  to  the  formation 
of  cold  abscesses.  It  is  frequently  seen 
accompanying  tuberculosis  of  the  joint, 
as  noted  by  Konig  and  Ehrhart. 

The  chief  symptom  is  the  presence 
of  a  hemispherical,  tense,  fluctuating 
tumor  beneath  the  deltoid;  it  is  of  pro- 
tracted duration  and  occasions  little 
discomfort.  Crepitus  may  be  obtained 
from  the  rubbing  together  of  the  rice- 
bodies;  sometimes  communication  with 
the  joint — as  in  a  case  of  Hyrtl's — is 
recognizable  from  the  bulging  of  the 
already  swollen  capsule  produced  by 
pressure  upon  the  tumor.  This  swell- 
ing of  the  capsule  can  be  felt  in  the 
axilla  and  obscures  the  contour  of  the 
head.  The  diagnosis  depends  chiefly  upon  the  history  and  the  presence 
of  a  tumor  beneath  the  deltoid,  easily  felt  if  the  muscle  is  contracted. 
Aspiration  gives  usually  only  serosanguineous  fluid,  or,  if  the  needle  is 
large  enough,  small  rice-bodies;  at  any  rate,  it  prevents  confusion  with 
a  neoplasm. 

The  diagnosis  is  aided  by  tuberculous  lesions  elsewhere,  as  in  Blauel's 
case. 

The  course  is  chronic. 

The  treatment  formerly  consisted  chiefly  in  aspirating  the  fluid  con- 
tents and  injecting  iodine;  later  the  tumors  were  opened  and  the  granu- 
lations scraped  out.  Total  extirpation,  as  repeatedly  employed  by  v. 
Bergmann,  v.  Bruns,  and  v.  Eiselsberg,  is  the  rational  procedure.  The 
tumor  is  exposed  by  a  longitudinal  incision  over  the  most  prominent 
point.  It  is  freed  at  the  sides  and  behind  and  peeled  out  in  toto;  if  the 
sac  is  very  large  it  may  be  necessary  first  to  evacuate  the  contents,  or, 


Hygroma  of  the  subdeltoid  bursa. 
i  v.  Bruns. 


80  DISEASES  OF  THE  SHOULDER. 

as  in  Blauel's  case,  make  a  long  posterior  incision;  the  latter  allows  free 
drainage. 

The  so-called  "creaking"  of  the  scapula,  felt  and  often  heard  at  a 
distance  during  movements  of  the  shoulder-blade,  is  attributed  to  the 
bursa  beneath  the  angle  of  the  scapula,  and  is  met  with  chiefly  in  thin 
subjects,  in  whom  the  scapula  lies  and  moves  almost  immediately  upon 
the  ribs.  Galvagni  has  seen  the  condition  many  times,  especially 
accompanying  pleurisy;  once  in  a  case  of  seamstress'  cramp;  in  another 
case  the  fifth  and  sixth  ribs  were  found  denuded  and  eroded  by  a  large 
subserrate  bursa.  Chronic  injury  may  give  rise  to  hygroma  ta  at  places 
in  the  shoulder  which  normally  contain  no  bursa.  Wegner  describes  a 
bursa  the  size  of  a  small  walnut  over  the  middle  of  the  clavicle,  produced 
by  the  irritation  of  the  gunstock  in  the  act  of  "shoulder  arms." 


INFLAMMATORY  PROCESSES  OF  THE  AXILLA. 

Inflammations  of  the  skin  of  the  axilla  are  frequent  by  reason  of  the 
abundance  of  sebaceous  and  sweat-glands.  Furuncles  are  occasionally 
very  protracted  and  apt  to  recur.  The  chronic  inflammation  of  the 
sweat-glands  described  by  Verneuil  as  hydradenitis  begins  as  deep- 
seated  firm  nodules  which  gradually  soften  and  suppurate — "sudoripa- 
rous abscesses."  The  process  is  often  stubborn,  and  repeated  crops  may 
cause  extensive  infiltration  of  the  skin.  Strong  disinfection  can  only  be 
employed  temporarily,  as  wet  bichloride  or  formalin  dressings  produce 
an  annoying  eczema  in  the  axilla;  on  the  other  hand,  aluminum  acetate 
is  excellent.     Abscesses  should  be  incised. 

The  lymph-glands  are  the  structures  most  affected  by  inflammatory 
processes  in  the  axilla.  All  infections  in  the  upper  extremity,  the  adja- 
cent thorax,  or  the  breasts,  may  produce  lymphadenitis  with  or  without 
a  recognizable  intercurrent  lymphangitis.  The  slight  and  often  unheeded 
wounds  of  the  fingers  are  the  most  frequent  contributing  causes.  Inflam- 
mation of  the  lymph-glands  is  evidenced  by  the  appearance  (often  rapid) 
in  the  axilla  of  tender  nodules  of  the  size  of  a  cherry  or  hazelnut.  In- 
volution may  be  equally  rapid  if  the  infection  at  the  source  is  checked 
early.  Spontaneous  resolution  is  aided  by  rest  and  the  application  of 
iodine  or  wet  dressings.  The  process  may  advance  to  suppuration  and 
periadenitis  with  adhesion  of  the  skin  and  to  perforation.  If  the  abscesses 
still  contain  a  large  amount  of  densely  infiltrated  gland-tissue,  persistent 
fistulas  may  result.  If  the  abscess  perforates  into  the  axillary  tissues, 
extensive  phlegmonous  abscesses  may  develop  in  the  axilla  and  beneath 
the  pectorals  with  high  fever  and  marked  constitutional  disturbance; 
sometimes  the  inflammation  begins  in  the  breast,  develops  beneath  the 
pectorals,  and  spreads  later  to  the  axilla. 

Tuberculosis  of  the  axillary  glands  is  not  rare,  although  not  so 
frequent  as  in  the  neck,  and  occurs  alone  or  with  tuberculosis  elsewhere 
(cervical  glands,  shoulder,  caries  of  the  ribs,  etc.).  Occasionally  the 
secondary  character  of  the  adenitis  may  be  determined  definitelv,  as  in 


ANEURISMS  IX  THE  AXILLA.  31 

the  case  of  lupus  or  tuberculosis  verrucosa  of  the  hand;  in  the  Tubingen 
clinic  tuberculous  adenitis  of  the  axilla  was  seen  in  2  students  who  had 
infected  their  fingers  while  dissecting  a  tuberculous  cadaver.  The  char- 
acter and  course  of  axillary  tuberculosis  show  the  same  variations  as 
those  of  cervical  adenitis  (which  see).  Gravitation  abscesses  in  tin- 
axilla,  from  processes  descending  along  the  vessels  of  the  neck  or  from 
disease,  pyogenic  or  tuberculous,  of  the  adjacent  bones,  ribs,  clavicle, 
scapula,  or  upper  end  of  the  humerus  or  of  the  shoulder-joint,  are  much 
less  frequent.  Perforating  actinomycosis  of  the  lung  may  also  cause  an 
axillary  abscess. 

Treatment. — The  treatment  of  axillary  abscesses,  except  in  the  case 
of  the  tuberculous  gravitation  abscess,  which  at  the  onset  is  aspirated 
and  injected  with  iodoform  emulsion,  is  usually  free  incision.  Based 
upon  the  favorable  experience  of  several  years,  tlie  author  always  follows 
the  incision  with  the  application  of  concentrated  carbolic  acid,  as  used 
by  Phelps,  providing  that  the  cavities  are  not  in  contact  with  the  large 
vessels.  For  fistulous  suppuration  of  the  glands  the  author  prefers 
removal  of  the  glandular  remnants  as  the  safest  and  quickest  method, 
although  it  cannot  be  denied  that  patience,  the  spoon,  and  silver  nitrate 
may  finally  effect  recovery.  Large  masses  of  tuberculous  glands  are 
indication  for  the  typical  cleaning  out  of  the  axilla.  (See  Vol.  II., 
page  60S.)  Thick  indurated  masses  extending  higher,  to  be  removed 
thoroughly,  may  necessitate  division  of  the  pectorali-. 


ANEURISMS  IN  THE  AXILLA. 

Aneurism  of  the  axillary  artery  results  either  from  atheroma  or  other 
diseases  of  the  vessels  or  from  injury  (which  see).  Of  69  cases  of 
aneurism  of  the  axillary  artery  collected  by  Koch,  32  occurred  spon- 
taneously or  without  special  cause,  12  from  a  fall,  a  blow,  and  over- 
exertion; 1  from  fracture,  4  in  reducing  dislocations,  and  9  each  from 
puncture  and  gunshot-wounds.  The  traumatic  cause  may  often  be  very 
slight;  Bardeleben  saw  an  aneurism  produced  by  the  pressure  of  a 
crutch.  The  mode  of  origin  of  traumatic  aneurisms  varies  according 
to  the  nature  of  the  injury:  a  wide  opening  in  the  vessel  may  allow  of 
diffuse  extravasation,  from  which  the  aneurism  may  be  formed  by  the 
gradual  cicatricial  thickening  of  the  adjacent  tissues,  or  the  wound  may 
first  close  and  the  aneurism  be  formed  later  by  the  stretching  of  the 
cicatrix,  as  produced  exceptionally  by  sudden  increase  in  blood-pressure; 
also  in  partial  lesions  of  the  coverings  by  ectasis  of  the  intact  adven- 
titia.  Spontaneous  aneurism  of  the  axillary  artery  is  most  frequent 
between  the  fortieth  and  fiftieth  years,  and  is  more  common  in  men 
than  in  women.  Of  591  aneurisms,  of  which  308  were  superficial  and 
accessible,  Crisp  found  18  in  the  axilla. 

Symptoms. — The  chief  symptom  of  axillary  aneurism  is  the  gradual 
development  of  an  ovoid,  round,  or  spindle-shaped  tumor,  either  beneath 
the  clavicle  in  the  triangle  between  the  clavicle  and  edge  of  the  pectoralis, 
Vol.  III.— 0 


32  DISEASES  OF  THE  SHO  ULDER. 

beneath  the  pectoralis  at  its  lower  margin,  or  in  the  axilla,  accord- 
ing as  the  growth  affects  the  first  or  last  portion  of  the  artery.  The 
pulsation,  isochronous  with  the  heart-systole,  and  the  blowing  murmur 
heard  over  the  aneurism  are  characteristic;  on  compressing  the  sul>- 
clavian  artery  these  symptoms  disappear.  The  tumor  is  usually  soft 
and  compressible;  this  quality  may  be  absent  if  there  is  a  moderate 
deposit  of  fibrin  in  the  sac.  Large  aneurisms  may  press  upon  the  plexus 
and  produce  numbness  in  the  fingers  and  arm,  radiating  pains,  and 
finally  oedema  and  coldness  from  obstruction  of  the  veins.  Very  large 
tumors  may  produce  gangrene.  From  the  above  symptoms  the  diagnosis 
is  not  difficult.  The  possibility  of  mistaking  aneurism  for  an  abscess 
is  known  and  dreaded,  but  is  dangerous  only  if  the  aneurism  is  treated 
as  such.     A  pulsating  sarcoma  may  also  be  confused  with  aneurism. 

The  course  is  usually  progressive:  as  a  rule  the  aneurism  extends 
downward  and  forward,  rarely  upward,  so  that  the  clavicle  is  pushed 
upward  and  dislocated  at  its  sternal  end,  and  the  first  and  second  ribs 
eroded.  Generally  a  spontaneous  aneurism  increases  more  slowly  and 
to  lesser  proportions  than  the  traumatic  variety.  If  far  advanced,  the 
chief  danger  lies  in  the  increasing  attenuation  of  the  coverings  and 
rupture  with  or  without  inflammation. 

Treatment. — The  treatment  is  essentially  operative.  Rest,  applica- 
tion of  ice,  and  compression  of  the  subclavian  by  intermittent  digital 
pressure  may  be  tried,  but  are  usually  not  well  borne.  In  the  majority 
of  instances  the  best  method  is  ligation  of  the  artery  above  and  below 
the  aneurism  and  evacuation  or  extirpation  of  the  sac.  Inflamma- 
tory adhesion  with  the  surrounding  structures  may  make  the  operation 
a  delicate  one;  the  greatest  difficulty  is  met  with  in  the  diffuse  extrava- 
sation of  the  early  stage  of  traumatic  aneurism  in  the  infraclavicular 
space.  (See  page  22.)  Hunter's  method  of  simple  ligation  of  the 
subclavian  has  not  given  good  results  in  the  case  of  axillary  aneurisms. 
(See  Popliteal  Aneurisms.) 

Several  instances  of  arteriovenous  aneurism  of  the  subclavian  beneath 
the  clavicle  and  of  the  axillary  have  been  seen,  most  frequently  following 
gunshot-wounds,  v.  Bramann  knows  of  6  cases  in  which  the  subclavian 
was  affected,  usually  beneath  the  clavicle,  and  5  of  the  axillary. 
As  a  rule,  the  communication  is  between  the  main  trunks  of  the  artery 
and  vein,  in  one  case  between  the  axillary  artery  and  basilar  vein.  For 
the  development,  anatomy,  and  symptoms,  see  Vol.  II.,  page  66  ff. 

The  functional  disturbances  are  usually  marked,  the  venous  con- 
gestion producing  enormous  swelling — even  3  inches'  difference  in  cir- 
cumference of  the  arm — subnormal  temperature  of  even  4°  to  8°  C, 
and  a  feeling  of  heaviness  and  muscular  weakness  in  the  arm  fre- 
quently resulting  in  complete  disability.  Simultaneous  injury  or  com- 
pression of  the  nerves  may  increase  the  disturbance.  For  these  condi- 
tions active  treatment  is  indicated.  Up  to  the  present  time  only  double 
ligation  of  both  vessels,  and  if  possible  extirpation  of  the  sac,  have  been 
beneficial;   by  this   method   v.    Bergmann   obtained   an   uninterrupted 


NEOPLASMS  OF  Till-:  AXILLA.  83 

recovery  in  a  case  of  axillary  arteriovenous  aneurism,  and  recently 
Erdmann  similarly  in  a  case  of  the  subclavian  aneurism  from  a  gunshot- 
wound  in  Mohrenheim's  space.  According  to  v.  Bramann's  statistics, 
compression  and  Hunter's  proximal  ligation  have  given  poor  results. 
How  far  the  modern  achievement  of  vascular  suture  is  applicable  to 
aneurism  of  the  axillary  remains  to  be  seen.     (See  Popliteal  Aneurism-. 


NEOPLASMS   OF  THE  AXILLA. 

The  benign  neoplasms  of  the  axilla  are  lipoma,  fibroma,  and  angioma. 
Lipoma,  either  with  a  broad  base  or  pedunculated,  is  not  infrequent 
and  often  attains  considerable  size.  Burow  saw  a  twenty-eight-pound 
lipoma  of  the  axilla.  Extirpation  is  usually  not  difficult;  attention  must 
be  paid  to  the  larger  of  the  veins  entering  the  tumor.  Angioma  occurs 
in  the  form  of  various  nsevoid  tumors,  either  congenital  or  as  a  mixed 
tumor  combined  with  lipoma.  The  cavernous  angioma  is  of  more 
practical  importance.  It  is  distinguishable  from  aneurism  by  the  swell- 
ing produced  by  coughing  and  pressure,  the  absence  of  pulsation,  the 
livid  color,  the  dilated  branches  of  the  vessels,  often  plainly  visible 
beneath  the  skin;  also  the  compressibility  and  mobility  of  the  tumor 
upon  the  deeper  structures,  and  the  fact  that  compression  of  the 
subclavian  produces  no  effect.  If  excision  is  counterindicated  by 
the  diffuseness  of  the  tumor,  thermopuncture  and  electropuncture 
are  in  order;  and  where  it  extends  deeply  and  widely,  the  injection  of 
alcohol. 

Lymphangioma,  cavernous  or  cystic,  develops,  analogous  to  cystic 
hygroma  of  the  neck,  chiefly  in  childhood  and  preferably  along  the 
lymphatics  in  the  axilla  and  upward  beneath  the  pectoralis  toward 
the  clavicle.  The  tumor  may  be  very  large  and  constricted  by  the 
pectoralis  as  by  a  purse-string.  A  hematoma  is  always  suggestive  of 
hemorrhage  from  the  walls  and  septa  of  a  previously  cystic  lymphan- 
gioma; the  etiology  can  be  cleared  up  only  by  a  microscopical  examina- 
tion. Among  the  benign  tumors  of  the  axilla  should  be  classified  the 
cases  of  aberrant  mamma.     (Compare  Vol.  II.,  page  562.) 

Malignant  tumors  of  the  axilla  usually  start  from  the  lymph-glands, 
and  are  then  generally  secondary;  we  are  justified  to-day  in  regarding 
as  doubtful  the  cases  of  primary  carcinoma  of  the  lymph-glands  occa- 
sionally reported.  Primary  sarcoma  may  arise  in  the  lymph-glands, 
the  vessels,  the  skin;  also  as  a  malignant  neuroma  it  is  often  seen 
attached  to  the  branches  of  the  nerves.  Primary  carcinoma  of  the  skin 
is  rare;  exceptionally  a  cicatrix,  papilloma,  or  lupus  can  be  demonstrated 
as  the  point  of  origin;  secondary  involvement  of  the  axillary  glands  is 
most  frequently  from  carcinoma  of  the  breast.  The  large  tumors  pro- 
duced in  the  axilla  by  Billroth's  malignant  lymphoma  have  already  been 
mentioned.      (See  Vol.  II.,  page  110.) 

For  the  technic  of  excision  of  malignant  tumors  of  the  axilla,  see 
Carcinoma  of   the  Breast,  Vol.  II.)     Interscapulothoracic  amputation 


84  DISEASES  OF  THE  SHOULDER. 

should  be  considered  when  the  tumor  involves  the  shoulder-joint  or  the 
vessels  and  nerves,  unless  operation  is  counterindicated  by  the  general 
condition  or  metastases. 


NEOPLASMS  IN  THE  SOFT  PARTS  OF  THE  SHOULDER. 

All  sorts  of  neoplasms  occur  in  the  shoulder:  angioma,  nsevus,  fibroma, 
keloid  after  burns,  sarcoma,  and  carcinoma.  The  shoulder  is  the  most 
frequent  site  of  lipoma,  which  often  grows  to  an  enormous  size  and 
develops  into  a  more  or  less  pendulous  tumor.  Such  a  tumor,  growing 
slowly  and  without  pain,  tense,  elastic,  and  often  giving  pseudofluctua- 
tion,  is  easily  recognized  by  its  lobulated  surface  and  can  be  confused 
only  with  hygroma  at  or  near  the  acromion.  Rarely  it  produces  sub- 
jective disturbances  independent  of  its  size;  lameness,  increasing  in  the 
course  of  years  with  the  growth  of  the  tumor,  as  noted  by  Vogt;  occa- 
sionally atrophy  of  the  muscles  of  the  thumb,  evident  at  an  early  period; 
also  slight  weakness  of  the  hand  and  varying  sensory  disturbances. 
Single  lobes  of  the  tumor  may  invade  the  fascia  between  the  muscles, 
or  the  tumor  may  begin  in  the  subfascial  tissues  and  gradually  push  its 
way  upward.  Lipoma  is  usually  excised  without  difficulty.  The  inci- 
sion should  be  made  so  as  to  produce  the  least  possible  disturbance; 
the  tumor  is  removed  by  blunt  dissection;  areas  partly  or  entirely 
excoriated  on  the  highest  portion  of  the  tumor  are  to  be  removed. 

A  peculiar  formation  of  the  skin  and  subcutaneous  tissue  resembling 
elephantiasis  is  described  by  Mott  and  Danzel  as  pachydermatocele, 
brownish  pigmented  growths  of  skin,  depending  in  folds  like  a  collar 
over  the  clavicle  and  shoulder.  It  is  a  hypertrophic  condition  of  the 
skin  and  subcutaneous  tissue.  Carcinoma  of  the  shoulder  is  rare; 
Schreiber  saw  such  in  the  case  of  a  pack-carrier,  the  growth  extending 
to  the  periosteum  and  eroding  the  spine  of  the  scapula.  It  started  from 
a  hygroma  over  the  spine  of  the  scapula. 

Tumors  of  the  deltoid  are  rare  and  are  chiefly  sarcomata,  as  noted 
by  Vallas,  Nove,  and  Delbet.  The  prognosis  is  usually  unfavorable. 
Recurrence  is  generally  rapid  so  that  extirpation  of  the  tumor,  recurrent 
operation,  exarticulation,  and  total  amputation  of  the  shoulder  follow 
each  other  rapidly,  as  in  a  case  reported  by  Heddaus  in  Czerny's  clinic; 
Schuh  records  a  neuroma  of  the  size  of  a  bean  excised  from  the  substance 
of  the  deltoid,  that  had  produced  unbearable  pain.  Recently  Honsell 
in  v.  Bruns'  clinic  described  an  enchondroma  of  the  size  of  two  fists 
that  in  two  weeks  had  grown  to  these  proportions  within  the  deltoid 
without  producing  any  particular  discomfort. 

The  so-called  "  exercise-bone" — in  hunters,  '"shooting-bone" — result- 
ing from  repeated  injury  while  exercising  and  turning,  particularly  in  the 
case  of  recruits,  is  a  form  of  ossification  occurring  in  the  deltoid  or  cora- 
cobrachialis;  it  is  probably  an  ossification  of  the  connective  tissue  which 
is  left  after  intramuscular  hemorrhages.  This  purely  local  bone  forma- 
tion gives  a  good  prognosis  in  contrast  to  progressive  ossifying  myositis. 


DISK  ISKS  OK   TIIK  CI. A  VICLE. 


85 


DISEASES  OF  THE  CLAVICLE. 

In  the  clavicle  acute  periostitis  and  ostitis  are  rare;  genuine  infec- 
tious osteomyelitis  is  equally  uncommon  in  the  clavicle,  Inn  may  produce 
extensive  or  total  necrosis.  Frohner's  statistics  from  v.  Brunss  clinic 
give  3  I  cases  of  acute  osteomyelitis  of  the  short  and  flat  hones  in  contrast 
to  170  of  the  long  bones;  the  clavicle  was  affected  in  8  cases.  In  2 
instances  of  total  necrosis  of  the  clavicle  there  was  subsequently  complete 
regeneration,  the  form  of  the  hone  and  the  function  of  the  arm  being 
preserved. 

Tuberculosis  of  the  shaft  of 
the  clavicle  is  rare  in  contrast 
to  the  frequency  of  osteal  foci 
observed  in  the  sternal  end. 
Syphilis,  both  hereditary  and 
acquired,  often  becomes  local- 
ized in  the  clavicle,  especially 
in  the  sternal  end,  in  the  form 
of  gummatous  protrusions — the 
so-called  tophi — which  may  sub- 
sequently soften  and  suppurate. 
If  the  growth  is  rapid,  it  may  be 
mistaken  for  sarcoma.  If  spe- 
cific treatment  does  not  bring 
about  healing  of  the  fistulse  and 
sequestra,  recovery  is  often  ef- 
fected rapidly  with  the  aid  of  the 
knife  and  sharp  spoon.  Enu- 
cleation or  partial  or  total  resec- 
tion are  indicated  in  tubercu- 
losis of  the  clavicle,  according 
to  the  amount  of  destruction 
present. 

The  joints  of  the  clavicle  are 
seldom  diseased.  Subluxation 
occasionally  takes  place  as  the 
result  of  diseases  which  cause 
forced    breathing;    also    as    the 

result  of  ankylosis  of  the  shoulder,  as  noted  by  Albert,  in  conse- 
quence of  the  greater  movements  required  of  the  sternoclavicular 
joint;  further  from  the  pressure  of  subclavicular  tumors — aneurism  of 
the  innominate,  as  reported  by  Holland.  Inflammatory  diseases  affect 
the  acromial  joint  less  frequently  than  the  sternal;  fibrous,  fungous,  and 
deforming-  arthritis,  occasionally  with  a  pathological  downward  subluxa- 
tion  of  the  scapula,  have  been  reported.  Tuberculous  caries  of  the 
sternoclavicular  joint  is  not  rare;  thorough  scraping  usually  checks  the 
process;  if  not,  resection  is  indicated.  This  joint  may  be  also  involved 
in  gummatous  processes;   occasionally  the  affection  is  bilateral.     If  the 


Fig.  54. 

% 

■  ■ 

1                    i& 

1 

^Ukttf 

Sarcoma  of  the  clavicle. 


86  DISEASES  OF  THE  SHOULDER. 

focus  has  perforated  outward,  scraping  may  be  necessary  in  addition 
to  potassium  iodide  internally.  According  to  Gurlt,  chronic  diseases  of 
the  clavicular  joints  frequently  accompany  those  of  the  shoulder-joint. 
Neuropathic  arthritis  of  the  sternoclavicular  joint  is  often  reported  in 
connection  with  syringomyelia. 

Neoplasms  are  rare  in  the  clavicle.  Osteoma  and  chondroma  arc 
most  frequently  seen  following  injury.  Osteosarcoma  and  myeloid 
sarcoma  have  been  reported  repeatedly;  Courtin  saw  an  instance  of 
rapidly  growing  osteosarcoma  neonatorum.  Resection  or  total  excision 
is  indicated  according  to  the  size  and  nature  of  the  tumor  (for  the  technic, 
see  later).  The  functional  result  is  favorable  even  after  total  excision 
by  which  the  periosteum  is  removed  and  regeneration  made  impossible. 
In  the  majority  of  instances  motion  of  the  arm  is  entirely  free  and  any 
depression  of  the  shoulder  scarcely  noticeable.  Norkus  in  1894  collected 
74  cases  of  total  excision  of  the  clavicle;  31  were  for  necrosis  and  caries, 
33  for  malignant  tumors,  and  3  for  gunshot-wounds. 


DISEASES  OF  THE  SCAPULA. 

Acute  periostitis  and  osteomyelitis  are  also  rare  in  the  scapula;  post- 
traumatic disease  affects  more  commonly  the  prominent  portions  of  the 
bone,  the  spine,  and  coracoid  process.  The  most  frequent  disease  of 
the  bone  is  tuberculosis,  either  in  the  form  of  typical  granulating  foci 
perforating  into  the  joint,  large  caseous  foci  in  the  body  or  spine, 
or  tuberculous  sequestra,  as  noted  by  Cousin.  The  course  is  usually 
protracted;  the  abscesses  may  reach  the  surface  by  a  circuitous  route; 
the  suppuration  may  be  very  exhausting.  Disease  of  the  spine  and  the 
lower  portion  of  the  scapula  will  demand  resection  more  frequently  than 
foci  about  the  joint;  in  the  latter  case,  if  the  joint  is  not  involved,  the 
operation  is  limited  to  removing  the  granulating  foci  or  sequestra.  For 
such  partial  resections  Kocher  advises  entrance  from  behind  through 
an  incision  carried  from  the  acromioclavicular  joint  over  the  shoulder, 
along  the  spine  of  the  scapula  to  about  its  middle,  and  then  in  a  curve 
downward  to  the  posterior  fold  of  the  axilla.  Rarely  total  resection  will 
be  indicated  for  extensive  caries  or  necrosis;  such  instances  are  occasion- 
ally reported.  Mikulicz  and  Hashimoto  have  shown  of  what  complete 
regeneration  the  scapula  is  capable  after  subperiosteal  resection. 

Tumors  of  the  scapula  are  not  particularly  rare,  and  are  seen  more 
frequently  in  children  than  in  adults.  The  benign  tumors  are  exostoses, 
osteoma,  fibroma,  cartilaginous  exostoses,  and  simple  enchondroma;  the 
more  frequent  malignant  tumors  are  colloid  and  cystic  chondroma, 
chondrosarcoma,  sarcoma,  and  carcinoma.  Among  72  cases  of  scapular 
tumors  Langenhagen  records  8  of  exostosis,  14  of  chondroma,  5  of 
fibroma,  23  of  carcinoma,  12  of  sarcoma,  and  2  undetermined.  Walder 
reports  19  cases  of  enchondroma,  30  of  carcinoma,  and  16  of  sarcoma. 

Myxochondroma  and  cystochondroma,  sarcoma  and  osteoid  sarcoma 
are  characterized  by  their  rapid  growth  and  tendency  to  metastasis.    The 


DISEASES  OF  THE  SCAPULA. 


87 


soft  sarcomata  are  very  apt  to  invade  the  muscles.  In  the  majority  of 
cases  the  tumor  arises  iii  the  body  of  the  scapula;  less  frequently  in  the 

processes,  the  spine,  or  the  angle.  It  usually  advances  toward  the  infra- 
spinate  or  supraspinate  fossa;  souk  times  it  grows  more  toward  the 
anterior  surface  and  appears  first  near  the  axilla,  as  noted  by  Ilclferich. 
As  soon  as  the  tumor  becomes  very  large  it  not  only  pushes  the  shoulder 
forward,  hut  also  presses  the  arm  downward,  possibly  causing  disloca- 
tion, as    noted    by    Bellamy.     It 

may    grow    forward.     Especially  ,I(i-  r,-r>- 

cystochondroma  and  myxochon- 
droma, chondrosarcoma,  sar- 
coma, and  osteoid  sarcoma  grow 
to  enormous  proportions,  weigh- 
ing even  30  pounds,  as  in  a  case 
reported  by  v.  Eiselsberg.  In- 
volvement of  the  glands  is  not 
constant  even  in  the  case  of  ex- 
tensive tumors.  Walder  collected 
25  cases  of  chondroma  of  the 
scapula  from  the  literature;  11 
were  colloid,  the  rest  were  cysto- 
chondroma. These  tumors  ap- 
pear generally  about  the  fortieth 
year,  while  the  pure  enchondro- 
mata  are  more  frequent  in  youth, 
and  grow  in  one  and  a  half  years 
to  the  size  of  a  fist  or  a  child's 
head. 

In  not  a  few  of  the  cases 
trauma,  such  as  a  blow,  a  fall 
upon  the  shoulder,  etc.,  is  given 
as  the  cause;  in  several  instances 
the  beginning  tumor  was  mistaken 
for  a  ruptured  muscle.  The  cases 
are  more  frequent  in  which  the 
already  existent  tumor,  previously 
manifesting  a  slow  growth,  was 
suddenly  stimulated  to  rapid 
growth  by  the  trauma. 

The  symptoms  at  the  outset  are  slight,  vague,  dull  pain  and  trifling 
impairment  of  motion,  so  that  the  disease  is  sometimes  regarded  as 
rheumatism,  as  noted  by  Sendler.  If  the  tumor  increases  slowly  toward 
the  subscapular  fossa,  it  may  be  mistaken  for  an  inflammatory  affection, 
particularly  if  it  is  deep  seated,  thickly  covered  by  the  soft  parts,  or  gives 
pseudofluctuation.  This  is  especially  the  case  if  its  development  is 
accompanied  by  fever.  Often  the  changed  configuration  and  the  dis- 
tended veins  of  the  shoulder  will  arouse  suspicion  before  any  considerable 
functional  disturbance  has  developed.     The  diagnosis,  so  simple  in  the 


Sarcoma  of  the  scapula. 


88 


DISEASES  OF  THE  SHOULDER. 


Fig 


case  of  large  tumors,  is  equally  difficult  sometimes  at  the  onset,  vet 
it  is  very  important  that  it  should  be  made  as  early  as  possible. 
In  doubtful  cases  aspiration  may  give  evidence  of  a  fluctuating 
swelling. 

The  prognosis  of  malignant  neoplasms  is  unfavorable;  particularly  the 
soft,  rapidly  growing  forms  advance  to  general  dissemination,  to  metas- 
tases in  the  inner  organs,  especially  in  the  lungs  and  pleura,  and  in  the 
vertebra?,  as  noted  by  Southam.  The  treatment  consists  in  the  earliest 
possible  radical  removal  of  the  tumor  and  in  the  majority  of  cases,  if 
shoulder-joint  and  arm  are  still  intact,  tins  means  total  excision 
of  the  scapula.     Partial  resection  is  justifiable  only  for  benign  tumors 

like  exostoses  or  for  secondary 
tumors  of  the  bones  arising  from 
the  soft  parts.  In  32  cases  of 
total  excision  of  the  scapula  with 
preservation  of  the  arm,  Doll  gives 
8  deaths  soon  after  the  operation, 
12  recurrences,  and  12  recoveries. 
In  the  cases  of  scapular  tumors 
operated  upon  subsequent  to  1S75, 
Schultz  gives  7  per  cent,  mortality, 
18  per  cent,  recurrence,  64  per 
cent,  of  recovery,  of  which  11 
per  cent,  was  verified  later  as 
permanent. 

In  many  cases  it  seems  advis- 
able also  to  remove  part  of  the 
head  of  the  humerus  or  a  larger 
portion  of  the  clavicle.  If  the 
neoplasm  involves  the  deltoid  or 
the  arm,  but  is  otherwise  still  oper- 
able, interscapulothoracic  ampu- 
tation is  indicated.  The  removal 
of  the  entire  shoulder  for  malig- 
nant tumors  subsequent  to  1875, 
the  year  of  the  introduction  of 
antisepsis,  resulted  in  13  per  cent, 
mortality  from  operation,  28  per 
cent,  mortality  from  recurrence  and  metastases,  57  per  cent,  of  recoveries 
— 2o  per  cent,  being  verified  later  as  permanent — in  3  percent,  the  result 
was  unknown.  From  the  statistics  available  at  the  present  time — Adel- 
mann,  Schwartz,  Gies,  Rogers,  and  Schultz — it  is  unquestionable  that 
the  earlier  the  operation  the  better  the  chances  of  recovery;  and  further, 
although  the  surgeon  too  often  sees  rapid  recurrence  following  his  best 
efforts,  it  must  be  remembered  that  a  second  operation  may  still  be 
successful-  The  result  represented  by  17  percent,  of  definite  recoveries 
can  still  be  improved  upon. 


Sarcoma  of  the  scapula    same  a-  Fi-;.  55  . 


>> 

(D 
■•-> 

s- 

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>> 

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INFLAMMATORY  DISEASES  OF  THE  SHOULDER  JOINT,       gy 


INFLAMMATORY  DISEASES  OF   THE   SHOULDER-JOINT. 

Inflammatory  diseases  of  the  shoulder-joint  are  seen  in  the  most 
diverse  forms,  both  acute  and  chronic,  severe  or  mild,  arising  from  the 
synovialis  or  from  the  bones,  especially  the  head  of  the  humerus,  and  with 
or  without  effusion.  The  effusion  may  be  serous,  sanguineous,  sero- 
fibrinous, seropurulent,  or  purulent.  The  disease  may  occur  alone  or 
be  a  local  manifestation  of  a  general  disease. 

On  account  of  the  thick  muscular  covering  and  deep  situation  of  the 
joint  the  changes  in  form  are  rarely  marked.  They  are  noticeable  only 
when  from  atrophy  of  the  muscles  and  relaxation  of  the  ligaments  the 
head  of  the   humerus  sinks  away 

from  the  glenoid  cavity,  or  when  Fig.  57. 

pathological  partial  or  complete 
dislocation  is  produced  by  fur- 
ther changes  in  the  structures  of 
the  joint.  The  symptoms  at  the 
onset  are  chiefly  impairment  of 
motion,  especially  of  abduction, 
and  pain.  It  is  only  in  certain 
forms  that  we  find  effusion  with 
bulging  at  the  bicipital  groove  or 
beneath  the  coracoid  process  or 
in  the  axilla.  In  regard  to  the 
diagnosis,  it  must  be  remembered 
that  many  affections  of  the  bursas 
of  the  shoulder  may  resemble  dis- 
eases of  the  joint:  and  further, 
they  are  not  infrequently  com- 
bined. In  testing  the  mobility 
one  should  always  notice  whether 
the  apparent  movement  at  the 
joint  is  not  transmitted  from  the 
scapula. 

Serous  and  Fibrous  Omarthri- 
tis.— The     tWO     forms     are     not  Sarcoma  of  the  scapula  (same  as  Fig.  55). 
easily    distinguished    from    each 

other,  as  the  resorption  of  the  primary  inflammatory  effusion  is  often 
followed  by  a  growth  of  vascular  connective  tissue  over  the  articular 
surfaces  and  by  inflammatory  adhesions  in  the  recesses  of  the  joint. 

Acute  serous  effusion  in  the  joint  is  observed  chiefly  after  injury, 
such  as  a  sprain  or  contusion.  Rarely  the  capsule  is  so  distended  that 
the  humerus  is  slightly  abducted  and  rotated  inward.  The  bulging  of 
the  capsule  is  usually  too  slight  to  be  noticeable.  Fluctuating  prom- 
inences at  the  points  related  above  occur  only  when  the  effusion  is 
very  marked.  The  swelling  may  be  more  uniform  if  the  periarticular 
tissue  is  involved  in  the  infiltration;  otherwise  swelling  in  the  region  of 
the  deltoid  should  always  suggest  involvement  of  the  subdeltoid  bursa. 


90  DISEASES  OF  THE  SHO  ULDER. 

Marked  dorsal  swelling  and  bulging  beneath  the  acromion  signify  dis- 
tention of  the  subacromial  and  subdeltoid  bursse.  By  pressing  upon  the 
joint  the  bulging  of  the  capsule  beneath  the  thin  covering  of  the  sub- 
scapularis  in  the  axilla  is  easily  recognized;  also  the  abnormal  mobility 
of  the  head,  as  the  condition  is  somewhat  of  the  nature  of  a  loose  joint. 
Exceptionally  the  distention  of  the  capsule  is  such  as  to  produce  a 
distention  dislocation,  as  noted  by  Malgaigne. 

This  form  of  inflammation  is  not  infrequently  a  local  manifestation 
of  an  infectious  disease,  as,  for  example,  acute  and  chronic  rheumatism; 
in  pyaemia  and  sepsis  the  involvement  of  the  joint  may  take  the  form 
of  a  pure  serous  or  fibrinous  inflammation.  Whereas  acute  rheumatic 
omarthritis  belongs  to  the  physician,  the  chronic  form,  by  reason  of  the 
necessary  prophylaxis  of  the  threatening  stiffness,  becomes  the  thankless 
task  of  the  surgeon.  In  the  advanced  stages  of  chronic  rheumatism  there 
are  more  marked  tissue-changes,  thickening  of  the  capsule,  villous 
growths,  forming  the  transition  to  the  picture  of  hyperplastic  inflam- 
mation. In  the  severest  form  there  are  adhesions  between  the  fibrin- 
covered  joint-surfaces,  and  finally  fibrous  or  bony  anchylosis. 

Symptoms. — The  symptoms  of  serofibrinous  and  fibrinous  omarthritis 
are  chiefly  functional:  impairment  of  the  movements  of  the  arm,  espe- 
cially abduction,  and  pain  on  passive  motion,  especially  rotation;  later, 
the  loosening  of  the  ligaments  and  the  action  of  gravity  produce  a  slight 
lowering  of  the  arm  so  that  the  acromion  becomes  more  prominent  and 
a  depression  can  be  seen  and  felt  between  it  and  the  head  of  the  humerus. 
Villous  growths  give  rise  to  more  or  less  fine  crepitus. 

Treatment. — The  treatment  consists  in  immobilization,  the  ice-bag  for 
severe  pain,  and  if  rheumatism  is  suspected,  45  to  65  grains  of  sodium 
salicylate  internally  daily.  If  the  effusion  does  not  yield  to  careful 
massage,  inunction,  or  iodine  locally,  subcutaneous  irrigation  of  the  joint 
with  3  per  cent,  carbolic  acid  or  1  :  5000  bichloride  solution  is  indicated. 
In  all  cases  of  irritation  of  the  joint  following  sprain  or  contusion  with 
or  without  htemarthrosis,  and  characterized  by  deficient  mobility  of  the 
shoulder-joint,  etc.,  the  patient  should  not  be  left  to  his  own  resources, 
as  he  is  content  to  carry  the  arm  in  a  sling  and  will  surely  obtain  a 
stiff  joint  if  not  obliged  to  work.     Compare  the  remarks  on  page  46. 

The  many  forms  of  balneotherapy  used  in  chronic  rheumatism  cannot 
be  discussed  here.  A  series  of  methods  depending  essentially  upon  the 
production  of  hyperaemia  belong  more  to  surgery,  however;  among  these 
the  hot-air  baths  (110°  C),  as  recommended  by  Krause  and  Bier,  for 
several  hours  daily.  Bier  commends  even  more  the  effect  of  passive 
congestion,  which'  the  author  has  also  found  valuable.  Particularly 
striking  is  its  favorable  action  upon  the  pain  and  stiffness.  It  cannot 
be  denied,  however,  that  its  application  here  is  more  difficult  and  less 
agreeable  than  at  the  more  peripheral  joints.  Bier  recommends  that  a 
cloth  sling  be  placed  around  the  neck  loosely,  the  ends  being  passed 
around  the  other  shoulder  in  the  form  of  a  spica  and  tied  in  the  axilla. 
A  well-padded  rubber  tube  is  applied  about  the  affected  shoulder,  the  ends 
drawn  sufficiently  tight  through  the  neckband  and  fastened  with  a  clamp; 


INFLAMMATORY  DISEASES  OF  THE  SHOULDER  JOINT.       91 

the  aeckband  prevents  the  tube  from  slipping  off;  the  hand  and  arm  are 
bandaged  snugly;  the  rubber  tube  may  be  left  on  (under  observation) 
for  twelve  hours.  The  results  obtained  up  to  the  present  time  by  opera- 
tion in  chronic  rheumatism  of  the  joint — arthrotomy,  resection,  etc. — do 

not  justify  the  indication  of  such  operations. 

Purulent  Omarthritis.  Purulent  inflammations  of  the  joint  may  be 
acute  or  chronic.  The  severesl  forms  of  acute  suppuration  follow  injury, 
such  as  compound  splinter-fractures,  gunshot-fractures  of  the  joint;  are 

transmitted  from  an  acute  osteomyelitis,  or  occur  during  the  infectious 
diseases  (smallpox,  pyaemia,  typhus,  scarlet,  or  puerperal  fever). 

Symptoms. — Acute  purulent  inflammation  of  the  joint  begins  with 
intense  pain,  high  fever,  marked  swelling,  and  severe  functional  disturb- 
ance. The  skin  rapidly  becomes  hot  and  red,  and  if  treatment  is  not 
energetic  or  the  patient  becomes  pyaemic  or  septic,  the  capsule  becomes 
perforated  and  the  abscess  appears  in  front  beneath  the  deltoid,  along 
the  biceps  or  at  the  lower  edge  of  the  subseapularis.  The  cartilage  is 
rapidly  destroyed  by  the  suppuration,  so  that  during  passive  motion, 
which  is  very  painful,  fine,  bony  crepitus  can  be  felt.  If  perforation 
outward  is  delayed,  the  periarticular  abscesses  may  burrow  extensively, 
and  lead  finally  to  the  formation  of  numerous  fistulas  about  the  scapula, 
on  the  thorax,  and  on  the  arm. 

Prognosis. — The  prognosis  varies  greatly  with  the  severity  of  the 
affection,  and  in  general  and  with  reference  to  the  function  is  unfavor- 
able. In  pyaemic  and  metastatic  suppuration  of  the  joint  the  general 
infection  almost  always  makes  the  prognosis  unfavorable,  whereas  single 
metastases  are  relatively  benign. 

Treatment. — "Ubi  pus,  ibi  evacuo,"  applies  to  suppuration  of  the 
shoulder-joint.  In  the  milder  forms  (the  so-called  catarrhal  suppuration) 
irrigation  with  3  per  cent,  carbolic  acid  or  1  :  1000  bichloride  solution  is 
justifiable.  Schede  obtained  good  results  in  this  way;  before  injecting, 
the  pus  should  be  aspirated  through  the  needle  and  sterilized  salt  solution 
injected  and  aspirated  on  account  of  the  coagulative  action  of  the  above 
chemicals.  If  the  irrigation  is  not  effectual  or  appears  a  priori  to  offer 
no  relief,  as,  for  example,  in  the  phlegmonous  form,  free  drainage  should 
be  obtained  by  arthrotomy,  preferably  behind  and  below;  and  if  this  fails, 
resection  is  indicated.  Further,  extensive  disease  of  the  soft  parts  of  the 
upper  arm  may  necessitate  amputation  at  the  shoulder.  If  antiseptic 
treatment  is  begun  early,  recovery  with  good  function  is  not  impossible. 
As  a  rule,  however,  suppuration  of  the  joint  is  followed  by  more  or  less 
complete  ankylosis.  Even  in  this  case  much  depends  upon  appropriate 
after-treatment.  If  recovery  with  ankylosis  is  probable,  the  joint  should 
be  fixed  in  slight  abduction. 

Gonorrhoea  and  syphilis  should  be  mentioned  particularly  as  special 
etiological  factors  liable  to  produce  serous  and  purulent  inflammation 
of  the  joint. 

Gonorrhoeal  arthritis,  first  properly  estimated  in  the  recent  works  of 
Xasse,  Bennecke,  and  others,  most  frequently  attacks  the  knee-joint — 
46  per  cent.    It  also  affects  the  shoulder-joint  alone  or  with  other  joints; 


92  DISEASES  OF  THE  SHO  ULDER. 

the  inflammation  is  more  often  serofibrinous  than  purulent,  and 
the  latter  form  does  not  usually  produce  as  much  destruction  of  the 
tissues  as  the  phlegmonous  suppuration;  it  has  more  the  character  of  the 
catarrhal  suppuration.  Benneeke  saw  4  cases,  2  severe  and  2  mild; 
Sehreiber  his  repeatedly  seen  serofibrinous  gonorrheal  omarthritis. 
The  metastases  in  the  joint  may  develop  at  any  stage  of  the  gonor- 
rhoea; the  onset  is  always  acnte.  The  symptoms  are  comparable  to 
those  of  acute  serofibrinous  omarthritis.  The  differential  diagnosis 
depends  upon  the  evidence  of  a  present  or  past  gonorrhoea.  In  the 
severer  cases  the  course  is  more  protracted.  The  prognosis  is  doubt- 
ful as  to  the  restoration  of  mobility.  In  the  treatment  the  same 
measures  are  applicable  as  in  the  case  of  rheumatic  inflammations. 
Bier  has  seen  particularly  good  results  from  passive  congestion. 
Operation  may  be  necessary.  In  one  instance  Konig  split  the  sheath 
of  the  biceps  tendon  down  to  the  joint,  irrigated  with  3  per  cent,  car- 
bolic acid,  and  in  one  year  obtained  almost  free  motion.  Schuchardt 
recommends  injection  of  a  1  per  cent,  solution  of  protargol. 

Syphilitic  omarthritis  may  occur  during  the  second  stage  and  is  usually 
serous;  commonly  other  joints — the  knee — are  also  involved;  in  the 
tertiary  stage  there  may  be  a  gummatous  synovitis  with  softening  and 
suppuration  in  the  joint.  Gummatous  foci  in  the  head  of  the  humerus 
may  involve  the  joint.  By  the  formation  of  fibrous  thickening,  cir- 
cumscribed hyperostoses,  and  irregular  defects  in  the  cartilage,  the  joint 
may  be  so  deformed  that  subluxation  takes  place.  The  head  may  be 
greatly  destroyed  by  gummatous  rarefaction.  The  treatment  is  specific, 
potassium  iodide  in  large  doses.     Operation  is  rarely  indicated. 

Tuberculous  Omarthritis. — The  shoulder-joint,  in  comparison  with 
other  joints,  is  rarely  affected  by  tuberculosis.  According  to  Billroth, 
caries  of  the  shoulder-joint  represents  2  per  cent,  of  the  cases.  Konig 
saw  60  cases,  in  38  of  which  the  right  side  was  affected,  in  22  the  left; 
in  25  per  cent,  the  primary  disease  was  synovial,  in  75  per  cent,  osteal. 
Gangolph  reports  29  of  32  cases  as  primarily  osteal.  According  to 
Mondan  and  Audry,  90  of  every  100  cases  of  chronic  arthritis  are  tuber- 
culous. The  disease  is  most  common  in  the  fourteenth  to  the  thirtieth 
year.     Trauma  is  not  infrequently  regarded  as  the  cause. 

Pathological  Anatomy. — The  pathologico-anatomical  changes  vary 
greatly  according  to  the  extent  of  the  disease.  Exceptionally  one  sees 
changes  in  the  form  of  circumscribed  nodules  arising  in  the  free  parts  of 
the  capsule  and  growing  into  its  substance.  In  the  majority  of  cases 
the  primary  synovial  form  is  diffuse,  the  membrane  being  filled  with 
numerous  gray  or  yellow-gray  nodules;  or  the  entire  membrane  is 
thickened  and  infiltrated,  presenting  the  so-called  fungous  swelling 
(omarthritis  fungosa);  or  there  is  a  cloudy  serous  effusion  or  puru- 
lent fluid  in  the  joint  containing  a  greater  or  lesser  quantity  of  fibrin. 
The  controversy  in  regard  to  the  origin  of  the  fibrin  cannot  be  entered 
into  here.  Fibrinous  hydrops  is  rare  in  this  joint.  The  grayish-red, 
soft  granulations,  which  protrude  on  cutting  into  such  a  joint,  invade 
the  cartilage  and  gradually  destroy  it,  producing  the  picture  of  caries 


INFLAMMATORY  DISEASES  OF  Til/:  siinrLhEll  JOIST.       93 

of  the  shoulder.  The  primary  foci  of  the  osteal  form  may  be  in  the  head 
of  the  humerus  or  in  the  glenoid  portion;  occasionally  one  finds  large 
cheesy  foci    and    characteristic    wedge-shaped    infarcts    or    tuberculous 


Fig.  58. 


Fig.  59. 


Tuberculous  sequesti 
end  of  the  femur. 


11  in  the  upper 
iv.  Bruns.) 


sequestra,  in  children  lying 
chiefly  near  the  epiphyseal 
line,  sometimes  centrally  in  a 
bony  cavity.     (Fig.  58.) 

The  most  frequent  form  of 
tuberculosis  of  the  shoulder- 
joint  is  the  so-called  caries 
sicca,  in  which  there  is  a  for- 
mation of  thin,  slightly  vascu- 
lar granulation-tissue,  which 
gradually  destroys  the  head. 
In  the  beginning  there  is  a 
formation  of  sinuous  furrows 
or  deep  cavities,  chiefly  along 
the  border  of  the  anatomical 
neck;  in  the  advanced  stages 
there  is  often  little  left  of  the 
head,  and    the    disease   may 

even  attack  the  shaft,  in  which  case,  in  younger  subjects,  there  may  be 
marked  changes  in  the  length  and  thickness  of  the  bone.  Caries  sicca, 
as  generally  described,  proceeds  without  suppuration  and  is  usually 
accompanied  by  shrinkage  of  the  capsule,  so  that  the  diminishing  head 
is  drawn  into  the  glenoid  cavity  or  against  the  coracoid  process.  (Fig. 
59.)     There  are  cases,  however,  in  which  the  entire  picture  is  that  of 


Caries  sicca  of  the  right  shoulder-joint  (front 
view).  The  head  of  the  humerus  (a)  is  practi- 
cally lacking,  the  remaining  portion  being  united 
so  firmly  to  the  almost  unaltered  glenoid  cavity 
(b)  by  tense  granulation-tissue  that  during  life 
motion  was  entirely  cheeked,  and  the  condition 
resembled  a  subcoracoid  dislocation.  c.  Cora- 
coid process,  d.  Acromion,  e.  Body  of  the  scap- 
ula sawed  off.  /.  Shaft  of  humerus.  (After 
Krause.) 


94  DISEASES  OF  THE  SHO  ULDER. 

caries  sicca,  but  in  which  fistulas  are  formed.  In  the  light  of  our  pres- 
ent knowledge  of  the  etiology  of  caries  sicca  these  transition  and  com- 
bination forms  seem  quite  natural.  Mondan  and  Audry  saw  27  cases 
with  suppuration  in  33  of  tuberculosis  of  the  joint.  In  the  author's 
experience  suppuration  is  a  fairly  frequent  occurrence  in  tuberculosis 
of  the  shoulder-joint.  The  author  has  already  mentioned  the  in- 
volvement of  the  periarticular  bursa?.  There  is  a  rare  form  called 
caries  carnosa,  in  which  the  spongy  bone  is  replaced  by  soft  sar- 
coid masses  filled  with  tubercles,  and  which  may  extend  into  the 
medulla. 

While  there  is  nothing  particularly  characteristic  in  the  clinical  course 
of  fungous  omarthritis  compared  with  the  other  forms  of  joint  tuber- 
culosis, the  picture  of  caries  sicca  of  the  shoulder-joint  is  typical.  In  the 
beginning  there  is  a  feeling  of  weakness  and  stiffness,  especially  in  the 
morning  on  arising,  soon  followed  by  more  or  less  active  attacks  of 
neuralgic  pain;  local  tenderness  is  particularly  marked  in  the  axilla  and 
at  the  greater  tuberosity  and  is  unaccompanied  by  marked  swelling. 
But  at  an  early  period  there  is  a  striking  flattening  of  the  shoulder, 
depending  partly  upon  the  atrophy  of  the  deltoid,  partly  upon  the 
atrophy  of  the  head.  This  results  in  the  sharp  projection  of  the  acromion, 
the  same  being  increased  occasionally  by  inward  and  downward  dis- 
placement of  the  head.  In  youthful  subjects  the  growth  of  the  head  of 
the  humerus  is  retarded. 

These  cases  are  often  mistaken,  especially  in  the  beginning,  for  joint 
neuroses;  for  rheumatism,  if  there  is  an  irregular  febrile  movement;  if 
developing  after  injury,  for  a  traumatic  inflammation  of  the  joint;  so 
that  Konig  says,  rightly,  "There  is  scarcely  a  joint  concerning  which  so 
many  sins  of  diagnosis  are  still  committed  at  the  present  time  with 
reference  to  tuberculosis  as  the  shoulder-joint."  Incipient  tumors  of 
the  head  of  the  humerus  may  be  mistaken  for  tuberculosis  of  the  joint; 
in  the  former  case  the  swelling  is  absent  in  the  joint  and  present  more 
at  the  epiphysis. 

Prognosis. — If  the  process  is  localized,  the  prognosis  as  to  life  is  not 
unfavorable;  unfortunately,  however,  the  disease  in  the  shoulder  is  fre- 
quently accompanied  by  tuberculosis  of  the  organs,  especially  the  lungs. 
The  prognosis  of  the  local  affection  varies  with  the  extent  of  the  process; 
extensive  fistulas  and  suppuration  are  less  favorable  on  account  of  the 
danger  of  cachexia.  Caries  sicca  usually  heals  in  one  to  two  years  with 
fibrous  ankylosis;  nevertheless  Konig,  in  resecting  a  case  of  ten  years' 
duration,  found  fairly  recent  foci.  Osteal  foci  give  the  best  prognosis, 
as  they  perforate  without  involving  the  joint  and  can  be  opened  without 
arthrotomy.  In  young  subjects  considerable  disturbance  in  growth  often 
persists  in  spite  of  favorable  recovery. 

Treatment. — At  the  onset  the  treatment  consists  solely  in  immobili- 
zation and  injection  of  iodoform.  By  passive  congestion  Bier  also 
obtained  good  results  in  caries  sicca.  It  is  not  advisable  to  try  to 
mobilize  a  stiff  joint.  Resection  is  indicated  for  the  cases  in  which  in 
spite  of  conservative  treatment  pain  and  functional  disturbance  persist 


INFLA  MM  A  TOR  Y  DISEASES  OF  THE  SHO  ULDER-JOIST.        95 


Fig.  60. 


and  suppuration  and  fistulas  appear;  by  removing  the  head  and  all 
tuberculous  tissue  in  the  capsule  and  glenoid  portion  of  the  joint,  more 
favorable  conditions  for  functional  recovery  arc  established.  Although 
it  cannot  be  denied  that  death  from  tuberculosis  follows  the  operation 
rapidly  in  individual  cases,  nevertheless  most  of  the  patients  arc  bene- 
fited by  resection  even  if  pulmonary  tuberculosis  occurs,  as  the  pain  is 
mitigated  and  the  arm  and  hand  made  more  useful.  In  children,  how- 
ever, resection  may  be  unnecessary,  as  foci — tuberculous  sequestra  are 
often  operable  without  removing  the  head.  Very  extensive  and  malig- 
nant tuberculosis  of  the  shoulder — caries  carnosa  of  Konig — may 
demand  amputation  of  the  humerus. 

Omarthritis  Deformans. — Arthritis  deformans  is  most  common  in 
advanced  age  and  affects  more  particularly  laborers  who  do  hard  work 
in  the  open  air;  it  is  not  infrequent  in  the  shoulder-joint.  It  is  well 
known  that  severe  injuries — fractures  of  the  joint,  dislocation,  sprain — 
may  be  the  cause  of  this  deforming  inflammation  in  addition  to  the 
slight  mechanical  and  atmospheric  influences,  to  which  the  joints  of 
laborers  are  usually  exposed.  If  everything  classified  in  the  present 
accident  insurance  practice  under  the  name  of  traumatic  arthritis  defor- 
mans should  be  accepted  scientifically,  the  etiological  significance  of 
trauma  would  be  overestimated.  Many  a  case  has  to  be  admitted  by 
the  court  as  traumatic  because  at  the  time 
of  the  decision  it  could  not  be  determined 
what  the  condition  of  the  joint  was  before 
the  accident.  In  other  instances  careful  ex- 
amination of  the  other  uninjured  shoulder- 
joint  demonstrates  that  here  also  the  de- 
forming process  is  already  well  advanced. 

Pathological  Anatomy. — The  hyperplastic 
and  regressive  changes  of  cartilage  and  bone 
occurring  in  arthritis  deformans  are  mani- 
fold. The  synovialis  may  be  covered  with 
villi  and  tuberous  growths,  the  capsule  thick- 
ened, the  head  of  the  humerus  enlarged  and 
with  growths  along  the  margin,  its  convexity 
flattened  and  worn  smooth  in  places.  (Fig. 
60.)  The  growths  along  the  margin  may  pro- 
ject like  fungi  or  in  part  become  free-bodies. 
The  glenoid  cavity  is  usually  circular,  at  times 
irregular,  broadened,  and  displaced  toward 
the  subscapular  surface.  There  may  be  a 
sort  of  partial  dislocation,  the  joint-surface 
being  divided  to  a  certain  extent  into  halves, 
the  dividing  ridge  corresponding  to  the  inner  border  of  the  joint.  Ex- 
ceptionally the  head  is  dislocated  more  toward  the  infraspinate  fossa; 
on  the  other  hand,  it  is  frequently  drawn  close  against  the  acromion 
by  the  shortening  of  the  capsule  and  the  tendon  of  the  supraspinatus. 
The  biceps  tendon  may  be  entirely  frayed  out  and   rupture   spontane- 


\ 


96  DISEASES  OF  THE  SHO  ULDER. 

ously.  The  amount  of  serous  effusion  varies  considerably.  There  is 
never  true  ankylosis. 

Symptoms. — The  symptoms  at  the  onset  are  slight  pain  and  impair- 
ment of  individual  movements,  especially  abduction  and  rotation.  Soon 
a  peculiar  crepitation  is  noticed  during  more  active  movements,  which 
may  be  evident  to  the  patient  and  heard  at  some  distance.  The  swelling 
of  the  capsule,  the  effusion,  and  the  enlargement  of  the  head  become 
more  and  more  noticeable  as  the  increasing  muscular  atrophy  hinders 
motion.  In  advanced  cases  the  diagnosis  is  seldom  difficult.  In  the 
early  stages  the  differentiation  from  chronic  rheumatism  may  be  difficult, 
especially  as  more  confusion  reigns  in  the  literature  on  these  two  diseases 
than  on  almost  any  other  one  subject. 

Prognosis. — The  prognosis  is  unfavorable;  in  the  majority  of  cases  the 
process  advances  steadily  and  remissions  are  rare. 

Treatment. — The  treatment  at  the  onset  consists  in  massage,  gymnastic 
exercises,  a  course  at  some  bath — Teplitz,  Wildbad,  Wiesbaden,  Gas- 
tein,  Ragatz — or  mud-baths;  also  the  various  methods  of  producing 
hyperemia — active  inunctions,  hot  air,  passive  congestion,  etc. — may 
now  and  then  exert  a  favorable  influence.  For  profuse  effusions  irriga- 
tion with  carbolic  acid  solution  is  indicated;  finally  protective  apparatus 
may  be  necessary.  Atrophy  of  the  muscles  should  be  combated  by  elec- 
tricity. Resection  may  be  demanded  for  severe  monarticular  disease  in 
young  patients. 

Neuropathic  Omarthritis. — Neuropathic  arthritis  of  the  shoulder 
occurs  in  the  course  of  various  diseases  of  the  central  nervous  system, 
chiefly  in  syringomyelia,  rarely  in  tabes.  The  arthropathy  of  syringo- 
myelia affects  more  particularly  the  upper  extremity — in  about  80  per 
cent,  of  the  cases — especially  the  shoulder-joint,  whereas  in  tabes  the 
joints  of  the  lower  extremity  are  more  often  affected — 76  to  SO  per  cent. 
Not  infrequently  several  joints  are  involved  at  the  same  time.  In  spite  of 
the  relatively  short  time  during  which  the  disease  has  been  recognized 
in  the  literature,  50  cases  of  shoulder  involvement  in  syringomyelia  are 
already  known,  whereas,  from  the  recent  statistics  of  Rotter,  Sonnen- 
burg,  Kredel,  and  Weizsaecker,  only  about  36  cases  from  tabes  are 
reported,  a  small  number  in  comparison  to  the  enormous  frequency  of 
tabes.  In  17  cases  of  syringomyelia  in  v.  Brims'  clinic  there  were  20 
arthropathies,  12  of  the  shoulder.  Schlesinger  estimates  the  frequency 
of  arthropathy  in  syringomyelia  at  about  20  to  25  percent.  Sometimes 
trauma  provokes  a  rapid  development  of  the  joint-affection;  in  other 
cases  it  merely  reveals  the  disease. 

Pathological  Anatomy. — The  anatomical  picture  is  extraordinarily 
characteristic.  Qualitatively  the  changes  are  those  of  arthritis  defor- 
mans, but  quantitatively  there  is  a  great  difference,  in  that  the 
effect  of  the  degenerative  processes  borders  on  the  grotesque.  The 
degree  of  growth  and  destruction  of  the  bone  reached  is  never  seen  in 
arthritis  deformans.  The  osteophyte  formation  extends  to  the  shaft; 
even  the  adjoining  muscles  may  be  ossified.  In  the  hypertrophic  form 
the  processes  of  growth,  producing  thickening  of  the  articular  surfaces, 


INFLAMMATORY  DISEASES  OF  THE  SHOULDER-JOINT.       97 

osteophytes,  marginal  masses,  and  villi,  predominate.     In  the  atrophic 

form,  the  more  frequent  in  the  shoulder,  there  is  rarefaction  of  the  hone 

even  to  the  complete  disappearance  of  the  articular  surfaces,  so  thai  the 
shoulder-joint  atrophies  the  same  as  in  caries  sicca.  Spontaneous 
dislocation  is  not  unusual  and  may  become  chronic  or  habitual,  in  that 
the  patient  can  produce  and  reduce  it  at  will.  Among  the  12  cases  in 
v.  Brims'  clinic  there  were  6  dislocations.     Previously  Schrader  collected 

Fig.  61. 


The  shoulder-joint  in  syringomyelia,     (y.  Bruns.) 


15  cases  in  connection  with  2  seen  in  v.  Brims'  clinic.  The  displacement 
of  the  deformed  head  may  be  extreme.  As  in  arthritis  deformans,  the 
amount  of  effusion  varies  greatly;  there  may  be  no  effusion  or  a  moderate 
hydrarthrosis  combined  with  bursitis  of  the  subdeltoid  bursa. 

Symptoms. — Aside  from  the  evident  deformity  the  most  marked  feature 
is  the  painlessness  of  the  fully  developed  affection.    There  is  something 
uncanny  in  the  reckless  manner  in  wdiich  the  patients  sometimes  go 
Vol.  III.— 7 


98  DISEASES  OF  THE  SHOULDER. 

about  with  their  deformed  limbs;  the  use  of  the  arm,  however,  is  often 
surprisingly  good  in  comparison  with  the  severity  of  the  deformity, 
providing  that  it  is  not  compromised  by  paralyses  or  mutilation  of  the 
fingers.  As  a  prodromal  sign  there  are  often  violent  attacks  or  crises 
of  pain. 

Diagnosis. — The  diagnosis  is  simple.  The  striking  changes  in  the 
joint  combined  with  the  absence  of  pain  should  suggest  a  central  disease 
to  the  experienced.  Atrophic  paralyses  of  the  upper,  spastic  paralyses 
of  the  lower  extremities,  abolition  of  pain-sense  and  temperature-sense, 
multiple  panaritia  and  their  effects  in  the  form  of  mutilations  of  the 
fingers — the  Morvan  type— verify  syringomyelia;  in  other  rare  cases,  as 
related,  the  well-known  symptoms  of  tabes  will  be  found. 

Prognosis. — The  prognosis  for  the  affected  joint  is  absolutely  bad, 
although  the  course  may  vary  greatly;  one  occasionally  sees  patients  in 
whom  the  changes  in  the  joint  have  reached  a  high  grade  in  a  relatively 
short  time  and  yet  which  after  years  are  apparently  stationary.  Sup- 
puration and  perforation  are  rather  frequent.  A  great  opportunity  for 
infection  is  given  in  the  multiple  panaritia  and  numerous  injuries  of  the 
skin  which  remain  unnoticed  on  account  of  the  analgesia.  As  to  the 
treatment:  the  author  has  not  attempted  operation  in  his  own  cases  in 
spite  of  occasional  favorable  results  reported  of  resection;  still,  the  latter 
may  be  rendered  inevitable  by  suppuration  of  the  joint,  as  in  Czerny's 
cases,  if  it  cannot  be  checked  by  antiseptic  irrigation.  In  one  case  the 
author  found  amputation  necessary  for  a  simultaneous  luxation  of  the 
elbow  with  fistulas.  Protective  apparatus  may  be  demanded  for  a  very 
loose  joint  or  a  tendency  to  dislocation.  Thanks  to  the  analgesia,  any 
necessary  operations  can  be  done  without  anaesthesia. 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  SHOULDER- JOINT. 

Stiffness  of  the  shoulder  may  develop  after  slight  injuries  of  the  joint, 
after  contusions,  sprains,  dislocations,  and  intra-articular  fractures;  also 
after  various  inflammatory  processes,  as  mentioned,  and  after  periar- 
ticular diseases.  The  development  of  a  contracture  may  be  overlooked, 
as  the  arm  by  its  weight  lies  against  the  thorax  and  the  patient  often 
deceives  himself  about  its  movements  in  believing  that  the  joint  moves, 
whereas  the  arm  is  abducted  by  the  rotation  of  the  scapula,  so  that  the 
impairment  of  motion  is  frequently  not  discovered  until  a  rapid  muscular 
atrophy  occasions  a  careful  examination. 

Contracture  at  the  shoulder  may  be  produced  by  cicatricial  contrac- 
tion and  processes  causing  shrinkage  of  the  skin  and  soft  parts.  In  the 
large  majority  of  cases,  however,  it  is  due  to  traumatic  or  pathological 
changes  in  the  joint  itself,  cicatricial  and  callous  shrinkage  of  the  capsule 
and  soft  parts  about  the  joint,  especially  at  the  lower  part,  hindering  ele- 
vation and  rotation  of  the  arm.  In  the  severer  cases  there  are  also  defects 
in  the  cartilage,  osteophytes,  and  fibrous  growths  producing  fibrous  and 
later  bony  adhesions  between  the  articular  surfaces. 


<<>S  TRACTURE  AM)  AXh'YLOSIS  OF  Till:  silo  I'LDER-JoI.XT.       99 

The  author  has  indicated  on  page  46  the  important  part  assumed 
by  modern  accident  insurance  in  the  subject  of  stiff  shoulder.  In  order 
to  estimate  the  disability  caused  by  still'  shoulder,  Thiem  states  that 
the  ability  to  lift  the  arm  to  a  horizontal  position  enables  the  patient  to 
do  general  work,  and  that  an  arm  abductible  to  a  horizontal  and  other- 
wise unimpaired  is  reduced  about  one-third  in  its  usefulness.  Complete 
stiffness  of  the  shoulder-joint,  the  other  joints  being  unimpaired,  permits 
of  motion  and  prehension  only  in  the  anterior  lower  third  of  the  normal 
sphere  of  motion,  the  disability  thus  being  slightly  above  75  per  cent. 
Such  a  range  of  activity,  however,  i>  better  than  none.  The  kind  of  work 
done  by  the  receiver  of  the  annuity  is  also  important  in  estimating  the 
latter.  These  patients  are  much  hindered  in  the  ordinary  daily  routine. 
If  the  ankylosis  occurs  in  youth,  the  entire  shoulder  zone  is  retarded 
in  growth  as  well  as  that  side  of  the  thorax,  so  that  later  there  may  be 
pronounced  asymmetry. 

Treatment. — The  prophylaxis  is  of  first  importance;  early  massage, 
later  passive  motion,  the  latter  often  making  great  demands  upon  the 
surgeon  and  patient.  The  scapula  and  clavicle  are  held  firmly  with  one 
hand,  the  other  grasps  the  semiflexed  elbow,  and  the  movement  of  the 
arm  is  gradually  increased  in  all  directions.  This  is  the  best  way  of 
preventing  the  shrinkage  of  fibrous  growths  and  the  formation  of  fibrous 
adhesions.  The  tendency  to  muscular  atrophy  is  combated  by  early 
local  faradism,  especially  of  the  deltoid.  The  treatment  is  much  more 
effectual  if  the  patient  can  be  made  to  aid  actively  in  the  movements. 
This  is  particularly  difficult  with  regard  to  elevation,  as  few  people 
possess  the  will-power  to  disregard  and  overcome  the  pain.  They  usually 
allow  the  arm  to  drop  helplessly  in  the  first  attempt  or  deceive  themselves 
and  the  surgeon  by  bending  the  spinal  column  and  rotating  the  scapula. 
The  surgeon  is  therefore  obliged  to  resort  to  various  artifices,  among 
which  Bardenheuer's  method,  especially  recommended  by  Thiem,  the 
author  has  used  many  times  with  success.  The  patient  folds  the  hands 
together  and  with  the  elbows  extended  lifts  the  arms  as  high  as  possible 
over  the  head  and  holds  them  there  for  some  time.  The  affected  arm  is 
at  first  elevated  by  the  other,  but  is  later  obliged  to  assist  as  the  latter 
becomes  tired.  The  exercise  should  be  repeated  as  often  as  possible  daily. 
In  the  case  of  recently  reduced  dislocations  Thiem  advises  that  in  the  first 
few  days  during  the  exercise  compression  should  be  made  at  the  joint 
to  prevent  dislocation.  After  some  progress  has  been  made  staff  exer- 
cises as  recommended  by  Hoffa  are  very  good  to  produce  active  mobili- 
zation. 

Gentle  stretching  of  the  shrunken  soft  parts  can  be  effected  by  con- 
tinuous extension  applied  in  the  intervals  between  the  exercises  and  dur- 
ing the  night.  The  gentlest,  least  painful,  and  most  satisfactory  way  of 
overcoming  the  contracture  is  by  means  of  apparatus  such  as  Reibmayr's 
with  elastic  traction;  or  Hoffa 's  with  screw  appliances;  or  the  Zander 
system  as  constructed  by  Hoffa,  Beely,  Ritschl,  and  others;  or  Kruken- 
berg's  pendulum  movements.  Such  apparatus  are  serviceable  only  in 
medico-mechanical  institutes  and  hospitals,  so  that  their  full  description 


100  DISEASES  OF  THE  SHOULDER. 

is  unnecessary  here.  Bier's  passive  congestion  is  a  valuable  aid  in  the 
medico-mechanical  treatment,  and  besides  its  well-known  action  in  alle- 
viating pain,  it  produces  marked  succulence  of  the  shrunken  soft  parts, 
so  that  they  become  more  plastic  and  extensible.  At  the  onset  a  muscular 
contracture  may  resemble  a  true  ankylosis,  so  that  anaesthesia  is  often 
necessary  to  determine  the  amount  of  contracture;  at  the  same  time 
mobilization  may  be  begun  by  gentle  motion.  The  formerly  customary 
method  of  forcible  tearing  has  been  abandoned,  as  the  lesions  of  the 
tissues  thus  produced  cause  renewed  inflammatory  irritation  and  hin- 
dered the  medico-mechanical  treatment;  where  the  ankylosis  is  resistant 
the  method  has  often  caused  fracture  and  fat-embolism. 

Firm  fibrous  and  bony  ankylosis  are  not  amenable  to  the  above 
methods  of  treatment.  Resection  is  necessary;  in  favorable  cases  the 
restoration  of  function  may  be  more  or  less  complete.  On  the  other 
hand,  a  loose  joint  may  result  and  the  remaining  active  control  of  the 
arm,  as  previously  effected  by  the  movements  of  the  scapula,  is  fully 
lost.  Consequently  the  surgeon  is  seeking  merely  a  functional  improve- 
ment and  not  the  removal  of  diseased  tissue;  thus,  this  most  valuable 
aid — namely,  resection — becomes  a  two-edged  sword  and  involves  a 
heavy  responsibility  in  determining  its  indication.  Where  the  age,  gen- 
eral condition,  and  mental  disposition  or  environment  seem  to  denote 
that  the  subsequent  treatment  essential  to  a  good  functional  result 
cannot  be  carried  out,  it  is  better  not  to  operate.  The  local  indication 
depends,  first  of  all,  upon  whether  the  muscles  of  the  shoulder,  especially 
the  deltoid,  are  functionally  adequate — electrical  test;  if  they  are  not, 
resection  would  be  a  mistake.  Likewise  the  technic  of  operation  should 
have  strict  regard  for  the  subsequent  muscular  function. 


LOOSE   SHOULDER-JOINT. 

A  loose  joint  may  be  the  result  of  extensive  loss  of  bone  following 
fracture,  gunshot-injury,  resection;  also  of  relaxation  of  the  capsule  fol- 
lowing inflammatory  effusions,  inflammatory  destruction  of  the  capsule, 
or  deformity  of  the  head  (arthritis  deformans  and  neurotica).  The  most 
frequent  cause  of  loose  joint  is  paralysis  of  the  shoulder  muscles,  espe- 
cially the  tensors  of  the  capsule.  It  follows  injuries  of  the  circumflex, 
the  suprascapular,  or  the  brachial  plexus;  also  intrapartum  separation 
of  the  epiphysis,  or  it  may  be  acquired  later  in  life.  The  deformity  is 
seldom  so  great  in  adults  as  in  the  young.  The  severest  cases  result 
from  infantile  spinal  paralysis. 

Symptoms. — The  arch  of  the  shoulder  is  flattened,  the  acromion  pro- 
jects forward  sharply,  and  between  it  and  the  sunken  head  of  the  humerus 
there  is  a  more  or  less  pronounced  depression,  often  sufficiently  wide  to 
admit  two  fingers.  (Fig.  62.)  The  arm  usually  hangs  relaxed  and 
commonly  rotated  inward ;  the  hand  is  pronated ;  active  elevation  of 
the  arm  is  impossible;  motion  is  limited  to  pendulous  movements  of 
the  arm  as  a  whole.     Passively  the  mobility  is  abnormal,  the  head  of  the 


LOOSE  SHOULDER  JOINT. 


101 


humerus    can    be    dislocated    in    all  Fig.  62. 

directions  and  can  be  pushed  up  to 

its  normal  position,  but  sinks  again 

to  the  position  allowed  by  the  relaxed 

capsule. 

Prognosis. — The  prognosis  is  un- 
favorable. The  condition  becomes 
worse  with  age;  the  head  of  the  hu- 
merus drops  farther  away  from  the 
acromion.  The  development  of  the 
shoulder,  the  arm,  and  the  same  side 
of  the  trunk  is  retarded. 

Treatment. — The  treatment  is  usu- 
ally limited  to  orthopedic  and  medico- 
mechanical  measures.  Zabludowski 
speaks  highly  of  the  results  obtained, 
even  in  cases  of  long  standing,  by 
strengthening  the  atrophic  muscles 
and  the  traction  powrer  of  the  auxil- 
iary muscles.  To  hold  the  head  in 
the  best  possible  position,  various 
apparatus  are  proposed.  Hoffa  rec- 
ommends the  appliance  proposed 
by  Schtissler  (Fig.  63);  by  means  of 
this  a  patient  who  had  had  a  severe 
paralysis  for  six  and  a  half  years  was 
able  to  write,  draw,  and  play  the 
piano.  The  apparatus  consists  essentially  of  a  shoulder-ring,  on  the 
inner  surface  of   wdiich  three  air-cushions    are    applied;   of  these,  the 


Loose  shoulder-joint  from  paralysis. 
(Hoffa.) 


Fig.  63. 


Schiissler's  apparatus  for  loose  shoultler-joint. 


two  smaller  triangular  pads  are  placed  in  front  and    behind  with  the 
apex  pointing  toward  the  axilla;  the  third,  large  and  rounded  pyram- 


102 


DISEASES  OF  THE  SHOULDER. 


idal  shaped,  is  placed  in  the  axilla  and  supports  the  head  of  the  hu- 
merus. Billroth'-  apparatus  is  shown  in  Fig.  04.  Collin's  is  similar. 
Other  apparatus  hold  the  head  up  by  means  of  rubber  bands. 

Fig.  64. 


Billroth'?  apparatus  for  loose  Bhoulder-joint. 

Arthrodesis  was  performed  unsuccessfully  by  Albert  in  1879;  success- 
fully by  J.  Wolff  and  Karewski.    The  head  of  the  humerus  is  sutured 

to  the  glenoid  cavity  and  if  possible  to  the  acromion  with  silver  wire; 
the  capsule  is  shortened  by  partial  excision.  Hoffa  obtained  improve- 
ment by  splitting  up  a  part  of  the  insertion  of  the  trapezius  and 
implanting  it  in  the  deltoid. 


NEUROSES  OF    THE  SHOULDER-JOINT. 


Joint-neuroses,  which  are  regarded  as  hysterical  and  have  been  made 
known  chiefly  by  Esmarch  as  a  painful  disease  of  the  joint  without 
anatomical  basis,  are  met  with  in  the  shoulder.  They  occur  very 
seldom  here,  as  compared  with  their  frequency  in  the  hip  and  knee.  In 
SO  cases  collected  by  Esmarch  only  4  involved  the  shoulder.  The  pains 
are  mostly  of  a  drawing  and  tearing  character  radiating  to  the  finger- 
tips and  into  the  neck;  they  disappear  as  a  rule  after  exertion,  rarely 
prevent  sleep,  and  become  more  severe  if  attention  is  paid  to  the 
patient.  There  is  sometimes  a  certain  amount  of  hypersesthesia;  the 
affected  part  is  more  sensitive  to  slight  touch  than  to  strong  pressure. 
The  plexus  is  especially  sensitive  to  pressure  in  Mohrenheim's  space; 
the    bicipital   groove   is    not    tender   as   it    is    in    inflammation  of  the 


NE  UR  OSES  ( >  F  Til  E  S II 0  ULDER  J01 A  T.  1 Q3 

shoulder-joint.  The  pain  elicited  by  pressing  the  articular  surfaces 
together,  so  marked  in  inflammatory  processes,  is  trifling. 

Objective  phenomena  may  be  absent  or  limited  to  a  peculiar  local 
(edema  and  occasional,  strikingly  periodic  temperature-changes  in  the 
entire  limb  or  the  joint.  Functionally  there  is  a  feeling  of  weakness; 
elevation  <>t'  the  arm  is  impossible;  the  scapula  participates  in  passive 
movement,  as  in  the  case  of  inflammation.  The  diagnosis  of  joint- 
neurosis  is  justifiable  only  after  prolonged  observation  and  accurate 
examination  have  failed  to  detect  organic  changes.  It  must  he  con- 
stantly held  in  mind  that  changes  in  the  bon( — caries  sicca,  gummatous 
ostitis — as  well  as  a  beginning  synovitis  may  he  accompanied  by  severe 
pain,  although  the  objective  findings  are  completely  negative  for  a  long 
while. 

Treatment. — ( General  and  psychical  treatment  are  often  of  chief  im- 
portance; secondarily  massage,  short  cold  sea-baths,  medico-mechanical 
treatment.  Local  rest  is  valueless;  on  the  other  hand,  improvement  is 
usually  rapid  as  soon  as  the  patient  is  compelled  to  use  the  arm. 


CHAPTER    III. 

OPERATIONS  ON  THE  SHOULDER. 

LIGATION  OF  THE  SUBCLAVIAN  ARTERY  BENEATH  THE 

CLAVICLE. 

This  operation  is  more  difficult  than  ligation  above  the  clavicle  on 
account  of  the  depth  of  the  wound,  particularly  in  muscular  subjects, 
and  the  number  of  veins.  The  incision  begins  h  inch  below  the  highest 
point  of  the  clavicle  and  runs  to  the  coracoid  process.  The  cephalic 
vein  at  the  anterior  border  of  the  deltoid  is  retracted  and  the  clavicular 
and  platysmal  portion  of  the  pectoralis  major  are  divided  in  the  direction 

Fig.  65. 


Ligation  of  the  subclavian  beneath  the  clavicle    D.  Deltoid.     M.  Median  nerve.     A.  Subclavian 
artery.      V.  Subclavian  vein.     F.   External  anterior  thoracic  nerve.     (Kocher.) 

of  the  wound.  The  cephalic  vein,  anterior  thoracic  nerves,  and  branches 
of  the  acromiothoracic  artery  are  drawn  upward,  the  coracoclavicular 
fascia  separated,  and  the  upper  border  of  the  pectoralis  minor  exposed. 
The  median  nerve  is  drawn  outward,  the  vein  to  its  inner  side  drawn 
inward,  the  artery  exposed  beneath,  and  the  aneurism-needle  passed 
under  from  the  inner  side.  (Fig.  65.)  Kocher  gives  also  a  longitudinal 
incision  along  the  groove  between  the  deltoid  and  pectoralis;  Chamber- 
(104) 


LIGATION  OF  THE  AXILLARY  ARTERY. 


105 


lain  recommends  a  two-limbed  incision  along  the  clavicle  and  the  above 
groove.  If  the  dissection  is  difficult,  especially  in  the  case  of  the  so-called 
diffuse  aneurism  following  injury  of  the  subclavian  artery,  a  vertical 
incision  with  temporary  resection  of  the  clavicle  and  division  of  the 
pectoralis  is  advisable. 

The  collateral  circulation  is  usually  established  after  ligation  of  the 
subclavian  artery  through  the  anastomoses  of  the  terminal  branches  of 
the  suprascapular  and  superficial  cervical  with  those  of  the  subscapular, 
intercostals,  and  thoracic.  If  it  is  necessary  to  ligate  the  artery  above 
the  exit  of  the  subscapular — for  example,  if  this  artery  is  torn — gangrene 
of  the  arm  may  occur;  the  danger  of  this,  however,  is  usually  slight 
even  if  there  is  a  simultaneous  injury  of  the  subclavian;  in  90  cases  of 
ligation  of  the  subclavian  v.  Bergmann  saw  only  3  cases  of  gangrene  of 
the  fingers  referable  to  it. 


LIGATION  OF  THE  AXILLAE Y  ARTERY. 

The  arm  is  supinated  and  abducted  and  an  incision  2h  inches  long 
made  along  the  inner  border  of  the  coracobrachialis.  (Fig.  66.)  On 
separating  the  fascia  a  bundle  of  nerves  containing  the  axillary  artery  is 
seen  beneath;  the  sheath  is  separated  and  the  anterior  strand — the  median 
and  musculocutaneous  nerves — is  drawn  forward;  the  posterior  strand 


A  R   V 
Ligation  of  the  axillary  artery.    M.  Median  nerve.     Cm.  Internal  cutaneous.      J?.  Ulnar  nerve. 
Cb.  Coracobrachialis  muscle.     A  and  V.  Axillary  artery  and  vein. 


— the  ulnar  and  musculospinal — is  drawn  backward  and  the  sheath  of 
the  artery  opened.  The  vein  lies  farther  back  at  the  posterior  border 
of  the  plexus  and  sometimes  divides  into  branches.  If  the  incision  is 
made  too  far  back  and  opens  upon  the  plexus  the  anterior  edge  of  the 
wound  must  be  drawn  forward  until  the  coracobrachialis  and  median 


10G  OPERATIONS  ON  THE  SHOULDER. 

nerve  are  exposed.     Less  frequently  the  exploration   and  ligation  of 

smaller  vessels  of  the  shoulder  will  require  a  special  procedure.  The 
posterior  circumflex  artery  is  easily  reached  by  an  incision  carried 
through  the  skin  and  fascia  1  inch  above  the  latissimus  and  along  the 
posterior  border  of  the  deltoid.  The  deltoid  is  pulled  forward  and  out- 
ward until  the  posterior  border  of  the  long  head  of  the  triceps  is  seen. 
The  outer  border  of  the  scapula  is  then  approached  between  the  teres 
major  and  minor  and  the  artery  found  close  to  the  bone  underneath  the 
teres  minor  by  incising  the  fascia.  The  suprascapular  is  found,  at  a 
point  corresponding  to  the  anterior  border  of  the  trapezius,  close  behind 
the  upper  border  of  the  clavicle  and  beneath  the  lower  belly  of  the 
omohyoid. 

RESECTION  OF    THE   SHOULDER-JOINT. 

In  resecting  for  injuries  or  pathological  processes  in  which  it  is  not 
necessary  to  remove  all  the  adjacent  tissues  (as  in  the  case  of  malignant 
neoplasms),  regard  for  the  latter  function  requires  that  the  muscular 
attachments  should  be  left  intact  with  the  periosteum  as  far  as  possible. 
This  is  done  in  a  typical  manner  by  the  subperiosteal  resection  methods 
of  Langenbeck  and  Oilier,  and  is  applicable  in  the  majority  of  cases. 

Resection  with  an  Anterior  Incision. — Langenbeck's  incision  begins 
at  the  anterior  border  of  the  acromion,  descends  2\  to  4  inches  along 
the  bicipital  groove,  and  penetrates  between  the  fibres  of  the  deltoid 
to  the  sheath  of  the  biceps.  The  latter  is  opened  at  the  inner  border  of 
the  groove,  divided  upward  to  the  origin  of  the  long  head  on  the  glenoid 
margin,  and  the  tendon  then  drawn  out  and  to  the  inner  side.  The  arm 
is  rotated  outward  strongly  and  the  periosteum  together  with  the  attach- 
ment of  the  subscapularis  separated  from  the  lesser  tuberosity;  in  the 
same  manner  with  the  arm  rotated  inward,  the  attachments  of  the 
supraspinatus,  infraspinatus,  and  teres  minor  are  separated  from  the 
greater  tuberosity.  The  muscular  insertions  will  be  preserved  better 
in  their  natural  relationship  if  the  tuberosities  are  chiselled  off,  as  advised 
by  Tiling,  or  the  superficial  lamina  of  bone  is  peeled  off  with  a  sharp 
raspatory — "subcortical  resection"  of  Kocher.  The  head  is  then  dis- 
located, protruded  from  the  wound,  and  sawed  off. 

Oilier  recommends  in  place  of  the  long  incision  an  oblique  incision 
beginning  at  the  clavicle  and  following  the  anterior  border  of  the  deltoid. 
The  cephalic  vein  is  drawn  inward.  The  deltoid  is  hooked  back  just 
below  its  origin  at  the  clavicle  and  a  branch  of  the  acromiothoracic 
artery  beneath  ligated.  The  muscle  is  drawn  outward  and  the  bicipital 
groove  exposed.  (Fig.  67.)  The  incision  has  the  advantage  of  preserv- 
ing the  deltoid  and  its  nerve  intact,  whereas  in  the  longitudinal  incision 
through  the  muscle  the  circumflex  nerve,  winding  around  the  posterior 
surface  of  the  neck  and  entering  the  under  surface  of  the  muscle  to 
supply  the  portion  lying  in  front  of  the  incision,  is  cut. 

Resection  with  a  Posterior  Incision. — Kocher  incises  from  the 
acromioclavicular  joint  over  the  arch  of  the  shoulder  along  the  spine  of 


RESKCTIOX  OF  THE  SHOULDER  JOIST. 


107 


the  scapula  to  its  middle,  thence  in  ;i  curve  downward  to  the  posterior 

fold  of  the  axilla.  The  acromial  joint  is  opened,  the  trapezius  divided 
on  the  upper  edge  of  the  spine,  the  posterior  border  of  the  deltoid  pulled 
forward,  and  after  blunt  elevation  of  the  supraspinatus  and  infraspinatus 
the  spine  is  chiselled  oil",  the  suprascapular  nerve  being  protected,  and 
the  acromiodeltoid  flap  swung  out  over  the  head  of  the  humerus,  to  be 
sutured  in  place  after  resection  is  completed.  Instead  of  resecting 
the  spine  temporarily  the  deltoid  may  he  lifted  off  by  chiselling  off  the 
hone  subcorticallv.  The  capsule  at  the  posterior  border  of  the  bicipital 
groove — anterior  border  of  the  supraspinatus  muscle  —  is  divided  up 
to  the  glenoid  margin  and  the  outward  rotators  elevated  from  the 
greater  tuberosity,  and  if  necessary  the  subscapulars  from  the  lesser 
tuberosity.     The  chief  advantages  claimed  by  Kocher  for  this  method, 


Resection  of  the  shoulder-joint  (Ollier's  incision):  a,  short  head  of  biceps  and  eoracobraehi- 
alis;  b.  clavicle;  c,  coracoid  process ;  d,  head  of  humerus ;  e,  point  at  which  to  divide  capsule  on 
anatomical  neck;  /,  bicipital  groove;  g,  long  biceps  tendon;  h,  deltoid;  i,  tendon  of  pectoralis; 
k,  cephalic  vein.     (Kocher.) 


aside  from  the  protection  of  all  the  important  structures,  are  the  free 
accessibility  of  the  glenoid  cavity  for  operations  and  the  possibility  of 
protecting  the  anterior  portion  of  the  capsule,  the  coracohumeral  liga- 
ment, and  attachment  of  the  subscapulars.  Bardenheuer's  transverse 
incision  differs  from  Kocher's  in  that  the  incision  lies  somewhat  more 
forward,  beginning  at  the  coracoid  process  and  ending  1  inch  below 
the  point  at  which  the  acromion  process  is  attached  to  the  scapula. 

Resection  with  Inferior  Incision. — For  old  dislocations  Langenbeck 
recommends  a  longitudinal  incision  at  the  posterior  border  of  the  cora- 
cobrachialis,  through  which  the  dislocated  head  is  approached  imme- 
diately beneath  the  axillary  fascia. 


1Q$  OPERATIONS  ON  THE  SHOULDER. 

The  termination  of  the  operation  with  the  removal  of  the  head  will 
depend  upon  the  conditions;  tuberculosis  will  demand  careful  inspection 
of  the  cavity,  the  removal  of  the  diseased  tissue  with  the  scalpel,  scissors, 
and  sharp  spoon,  and  if  the  foci  cannot  he  cleaned  out  with  a  sharp  spoon, 
resection  of  the  diseased  glenoid  portion.  Konig  notes  that  in  such 
extensive  operations  it  may  be  necessary  to  ligate  the  posterior  circum- 
flex artery;  the  same  applies  to  the  anterior  circumflex  if  the  operation 
is  carried  down  upon  the  humerus  (cave  nerv.  circumflex.!).  In  general 
the  author  removes  as  little  of  the  head  as  possible,  in  contrast  to  the 
typical  infratubereular  resection,  as  the  danger  of  displacement  beneath 
the  coracoid  process  and  of  loose  joint  increases  with  the  amount  of 
bone  resected.  In  children  particularly  it  is  important  to  preserve  the 
epiphyseal  line,  as  the  growth  of  the  humerus  in  length  depends  chiefly 
upon  the  upper  epiphysis.  These  conservative  principles  are  hardly 
reconcilable  with  Htiter's  proposal  to  expose  the  neck  subperiosteal^' 
first,  divide  the  head  with  a  pointed  saw,  and  then  remove  it,  but  where 
the  ankylosis  is  very  firm  this  may  be  necessary.  How  far  the  wound 
will  be  sutured  primarily  will  depend  upon  the  case;  it  is  advisable  under 
all  circumstances  to  leave  an  opening  for  drainage  at  the  lower  posterior 
end  at  the  border  of  the  latissimus,  the  most  favorable  point;  in  the 
anterior  longitudinal  incision  the  lower  angle  of  the  wound  can  be  left 
open. 

Great  stress  should  be  laid  upon  careful  after-treatment.  In  applying 
the  first  bandage  a  cotton  pad  should  be  placed  in  the  axilla  to  prevent 
inward  displacement  of  the  resected  humerus.  Extension  is  advocated 
by  many.  As  soon  as  the  wound  is  healed,  massage,  electricity,  and 
careful  passive  motion  should  be  instituted;  active  movements  of  the 
fingers,  the  hand,  and  the  elbow  should  begin  earlier.  The  upper  end 
of  the  humerus  should  not  be  moved  until  the  end  of  the  fourth  week, 
and  then  under  accurate  control  and  with  gradual  increase.  Other 
things  being  equal  the  functional  result  depends  chiefly  upon  the  sub- 
sequent exercise  and  electricity;  in  fact,  a  passively  loose  joint  can  still 
be  made  useful  if  properly  treated,  as  shown  by  v.  Langenbeck.  The 
earlier  statistics  of  the  mortality  following  resection  of  the  shoulder — 
namely,  in  military  practice  an  average  of  35  per  cent.,  in  pathological 
processes  18  per  cent. — are  no  longer  applicable.  Resection  of  the 
shoulder  is  to-day  a  relatively  safe  operation.  The  excellent  functional 
results  reported  by  v.  Langenbeck,  Volkmann,  and  Oilier,  and  the  com- 
plete nearthroses  verified  anatomically  by  Textor  and  Oilier,  are  en- 
couraging for  a  broader  application  of  resection,  particularly  for  extensive 
diseases  of  the  shoulder  with  suppuration  and  fistulas. 


AMPUTATION  AT  THE  SHOULDER. 

Exarticulation  of  the  arm  may  be  indicated  by  injuries,  particularly 
those  produced  by  heavy  ordnance,  crushing,  etc.,  and  by  various  diseases 
— septic  processes,  tumors.     The  methods  of  amputation  are  numerous; 


AMPUTATION  AT  THE  SHOULDER.  [09 

further,  the  individual  type  may  be  greatly  modified  under  circum- 
stances. The  method  will  always  be  chosen  which  gives  the  quickest 
control  of  the  large  vessels,  as  digital  compression  of  the  subclavian 
during  the  operation  is  never  certain.  The  laceration  of  the  soft  parts 
produced  by  severe  crushing,  bombshell  injuries,  etc.,  may  be  so  exten- 
sive that  the  vessels  lie  free  in  the  wound  or  are  lorn  and  require  imme- 
diate ligation. 

Amputation  Preceded  by  High  Amputation  of  the  Upper  Arm.— 
The  Esmarch  bandage  is  applied  like  a  spica  around  the  arm,  the  end 
fastened  upon  the  other  side  of  the  thorax,  or,  better,  held  by  an  assistant 
in  order  not  to  interfere  with  breathing;  a  single  circular  incision  is 
made  at  the  level  of  the  anterior  fold  of  the  axilla,  the  vessels  ligated, 
and  the  bandage  removed.  An  anterior  resection  incision  is  then  added, 
the  upper  end  of  the  humerus  removed  (see  the  technic  of  resection), 
and  the  operation  completed.  As  a  rule  the  high  amputation  can  he 
done  away  with,  as  the  hemorrhage  can  he  controlled  accurately  without 
the  Esmarch  by  the  following  method: 

Amputation  by  the  Oval  Method  (Kocher's  Anterior  Lancet  Inci- 
sion).— Through  a  longitudinal  incision  beginning  at  the  inner  side  of 
the  coracoid  process  the  anterior  fibres  of  the  deltoid  are  divided,  the 
cephalic  vein  ligated;  the  incision  is  then  carried  down  to  the  bone  from 
the  margin  of  the  deltoid,  the  capsule  separated  in  front  of  the  bicipital 
groove  and  lifted  off  with  the  tendon  of  the  subscapularis,  the  attach- 
ment of  the  pectoralis  major,  the  latissimus,  and  teres  major.  The 
capsule  upon  the  summit  of  the  head  and  behind  the  greater  tuberosity, 
the  attachments  of  the  supraspinatus,  infraspinatus,  and  teres  minor  are 
divided,  the  head  of  the  humerus  dislocated  outward,  and  the  skin  inci- 
sion completed  by  a  circular  cut  at  the  level  of  the  axillary  fold.  This  in- 
cision is  only  through  the  skin,  so  that  the  nerve-sheath  and  vessel-sheath 
can  be  isolated,  the  vessels  ligated,  and  the  nerves  divided.  Care  should 
be  taken  to  avoid  the  circumflex  winding  about  the  head  above  the  teres 
major  and  running  to  the  deltoid.  At  the  beginning  of  the  operation 
the  vessels  may  be  ligated  at  the  lower  border  of  the  pectoralis  minor 
without  difficulty,  as  proposed  by  Hiiter.  If  in  the  case  concerned  the 
soft  parts  can  be  preserved,  subperiosteal  excision  of  the  bone  and  the 
preservation  of  the  natural  attachment  of  the  muscles  to  the  periosteum 
have  the  great  advantage  of  giving  a  well-formed  and  more  movable 
stump  and  permit  of  better  application  of  the  prothesis. 

Amputation  with  a  Flap  Incision. — The  U-formed  flap  incision  of 
Langenbeck,  encircling  and  including  the  entire  deltoid,  is  the  one  most 
generally  used.  The  incision  is  made  with  a  medium-sized  amputation- 
knife  beginning  at  the  coracoid  process  and  encircling  the  deltoid  to 
end  at  the  spine  of  the  scapula.  The  knife  is  held  obliquely  throughout 
in  order  that  the  skin-flap  may  be  greater  than  the  muscular  flap.  The 
flap  is  then  turned  upward,  the  joint  opened  from  above,  and  the  head 
pushed  out  so  as  to  allow  the  introduction  of  the  knife  behind.  An 
assistant  compresses  the  axillary  bridge  of  soft  parts  containing  the 
vessels  with  the  thumbs  in  the  wound  and  the  other  fingers  in  the  axilla, 


HO  OPERATIONS  ON  THE  SHOULDER. 

while  the  knife  is  drawn  downward  close  against  the  bone  and  then 
through  into  the  axilla  to  form  a  small  axillary  flap;  the  vessels  are  then 
ligated. 

Defects  of  the  soft  parts  which  compel  a  flap  incision  may  also  neces- 
sitate an  atypical  operation,  as  the  skin  will  have  to  be  used  where  it  is 
found.  In  the  case  of  malignant  tumors  preventing  preservation  of  the 
muscles,  the  most  natural  method  will  be  the  formation  of  an  upper 
large  skin-flap  to  cover  in  the  wound.  Where  the  tumor  has  extended 
beyond  the  bone,  it  is  self-understood  that  careful  dissection  is  necessary. 

Robuchon  estimates  the  mortality  of  primary  amputation  in  various 
wars  at  50  per  cent.;  Fischer  gives  66  per  cent.;  Schede,  24  per  cent, 
for  primary  and  47  per  cent,  for  secondary  amputation.  Naturally 
the  results  during  the  antiseptic  era  are  much  better;  Schede  cites  9 
and  Bardenheuer  12  amputations  of  the  arm  with  only  1  death.  Accord- 
ing to  Scudder's  statistics  from  the  Massachusetts  General  Hospital,  the 
mortality  from  amputations  for  trauma  was  32  per  cent,  in  contrast  to 
53  per  cent,  during  the  preantiseptic  period,  and  from  amputations 
for  pathological  processes  0  per  cent. 


RESECTION  AND  EXCISION  OF   THE  CLAVICLE. 

Resection  of  the  Sternal  Joint. — This  may  be  necessary  in  caries  of 
the  joint  or  to  give  access  to  the  deeper  structures.  The  incision  is  made 
parallel  to  the  long  axis  of  the  clavicle  and  down  to  the  joint,  and  is 
supplemented  if  necessary  by  a  short  vertical  incision  at  its  inner  end; 
the  periosteum  is  lifted  off,  the  sternal  end  pulled  out  with  the  elevator 
and  removed,  or  the  clavicle  is  sawed  off  with  a  Gigli  saw  at  an  appro- 
priate distance  from  the  joint.  The  outer  end  of  the  sternal  piece  is 
seized  with  forceps  and  separated  carefully  with  the  raspatory  and 
bone-knife  from  the  soft  parts,  the  jugular  vein  being  avoided.  In 
extracapsular  resection  the  venous  arch  of  the  jugulars  should  be 
guarded.  The  diseased  articular  surface  of  the  sternum  is  best  chiselled 
off  from  above  forward  and  outward,  and  if  displacement  of  the  clavicular 
stump  is  apprehended,  the  bones  should  be  united  with  a  wire  suture. 

Resection  of  the  Acromial  Joint. — This  operation  may  be  necessary 
for  caries  or  for  old  or  troublesome  dislocations  of  the  clavicle.  Through 
an  incision  on  the  anterior  surface  of  the  outer  end  of  the  clavicle  the 
periosteum  is  stripped  off,  the  ligaments  of  the  joint  divided,  and  the 
end  of  the  bone  sawed  off;  all  diseased  portions  are  removed  with  the 
saw  or  rongeur.  The  stump  is  either  sutured  in  place  with  silver  wire 
or  the  ligaments  merely  sutured  over  it. 

Excision  of  the  Clavicle. — Removal  of  the  clavicle  may  be  necessary 
in  caries  or  necrosis,  more  commonly  for  malignant  neoplasms.  As 
done  subperiosteally  for  necrosis  the  operation  is  simple.  In  removing 
tumors  involving  the  periosteum  and  the  adjacent  muscles  the  subclavian 
vein  and  the  pleura  of  the  apex  must  be  avoided.  Through  a  longitudinal 
incision  running  the  length  of  the  bone  the  acromioclavicular  joint  is 


RESECTION  OF  THE  SCAPULA.  \\\ 

first  opened,  the  clavicle  is  then  pulled  upward  forcibly  and  separated 
gradually  from  without  inward  from  the  deltoid  and  pectoralis  major. 
The  coracoclavicular  ligament  is  divided  and  the  subclavian  muscle  and 
costoclavicular  ligaments  are  freed,  the  adjacent  structures  being  mean- 
while avoided.  The  trapezius  and  cleidal  portion  of  the  sternomastoid 
are  freed  from  the  upper  border. 

Resection  of  the  Clavicle  in  Continuity.— Generally  it  is  best  to 
resect  subperiosteally  if  possible  through  an  anterior  longitudinal  inci- 
sion and  use  the  Gigli  saw,  as  it  is  difficult  to  chisel  the  hard  bone.  If 
the  saw-line  is  made  oblique  or  zigzag,  it  is  easier  to  suture  and  to  prevent 
overlapping  of  the  surfaces. 


RESECTION  OF  THE  SCAPULA. 

Total  Resection. — The  chief  indication  is  given  by  malignant  neo- 
plasms involving  the  larger  portion  of  the  scapula.  If  the  axillary  glands 
are  involved,  they  are  also  removed;  the  operation  is  not  possible  if  the 
tumor  has  invaded  the  axillary  vessels — which  happens  in  about  one- 
third  of  the  cases — or  if  the  tumor  has  spread  to  the  shoulder-joint  and 
arm.  Extirpation  is  necessary  less  frequently  for  inflammations  of  the 
bone  (Escher,  Paci,  Oilier),  tuberculosis  (Ceci),  necrosis  following 
typhoid  (Duplay),  and  exceptionally  for  injuries  from  heavy  ordnance 
(v.  Langenbeck)  or  gunshot- wrounds  in  general  (Whelan,  Douglas, 
Bennet,  and  others). 

In  operations  for  injuries  and  inflammatory  affections,  the  bony 
processes  (acromion,  coracoid),  to  which  the  muscles  are  attached,  are 
preserved  with  their  periosteum  as  far  as  possible,  whereas  malignant 
tumors  demand  radical  removal  of  all  involved  tissue. 

The  majority  of  operators  prefer  an  incision  along  the  spine  and  inner 
border  of  the  scapula.  A  curved  incision  is  made  from  the  acromion 
along  the  spine  to  the  internal  border  and  then  downward  to  the  angle 
of  the  scapula.  If  the  acromion  is  to  be  preserved,  it  is  chiselled  off; 
if  it  is  to  be  removed,  the  incision  begins  by  opening  the  acromiocla- 
vicular joint.  The  triangular  flap  thus  made  is  drawn  down  and  outward 
to  the  border  of  the  latissimus,  the  deltoid  lifted  upon  the  fingers  and 
divided,  and  the  posterior  surface  of  the  capsule  and  the  tendons  of  the 
outward  rotators  exposed.  The  muscles  are  divided  in  order  upon  an 
elevator  or  the  fingers,  and  if  the  joint-portion  of  the  scapula  is  to  be 
preserved,  it  is  sawed  off.  If  the  resection  is  for  a  tumor,  the  tendons 
of  the  rotators  are  separated  from  the  head  of  the  humerus,  as  in  resec- 
tion of  the  humerus;  below,  the  attachment  of  the  latissimus  dorsi  and 
teres  major  are  separated  from  the  lesser  tuberosity,  the  circumflex  nerve 
and  artery  protected  at  the  lower  border  of  the  teres  minor,  and  the 
artery  then  ligated  farther  back.  The  trapezius  is  separated  from  the 
spine  and  the  acromial  branches  of  the  acromiothoracic  artery  tied  at 
the  outer  end.  The  scapula  is  then  drawn  down  and  the  muscles 
attached  to  its  upper  border  divided;  the  omohyoid  and  levator  scapulae 


112  OPERA  TIONS  ON  THE  SHO  ULDEB. 

are  freed  from  the  upper  angle  and  the  terminal  branch  of  the 
suprascapular  and  the  branches  of  the  dorsal  artery  of  the  scapula 
tied.  The  scapula  is  then  turned  over,  the  attachment  of  the  serratus 
major  on  the  posterior  border  and  the  attachments  of  the  rhomboids 
divided  and  the  dorsal  artery,  running  along  the  border  of  the  scapula 
upon  the  serratus,  tied.  All  skin  affected  in  the  case  of  neoplasms  is 
removed  with  a  margin  of  healthy  skin  and  appropriate  flaps  formed. 

The  prognosis  varies  in  the  statistics  published.  In  the  pre-antiseptic 
period  the  mortality  from  the  operation  was  17  per  cent.,  recoveries  30 
per  cent.;  in  the  antiseptic  period  the  mortality  from  operation  is  7  per 
cent.,  recoveries  64  per  cent.  The  statistics  of  various  authors  show 
rather  wide  deviations  from  these  figures.  The  functional  result  was 
generally  good.  The  statistics  of  Adelmann,  Gies,  Putti,  and  Poinsot 
show  good  function  of  the  arm  in  about  65  per  cent,  of  the  cases. 

Partial  Resection. — Amputation  of  the  scapula  with  preservation 
of  the  joint  has  already  been  described.  Resection  of  the  acromion  and 
spine  is  effected  through  an  incision  along  the  spine;  in  the  case  of 
tumors  the  periosteum  and  all  involved  adjacent  tissues  are  removed. 
Resection  of  the  angle  of  the  scapula  is  done  through  an  oblique  incision, 
prolonged  vertically  if  necessary,  or  through  an  angular  incision  following 
the  line  of  the  scapula.  For  resection  of  the  joint-portion  Esmarch  and 
Vogt  have  suggested  several  methods:  Esmarch  makes  a  curved  incision 
\  inch  from  the  tip  of  the  acromion,  along  its  lower  border  and  extending 
4  inches  backward;  he  divides  the  fibres  of  the  deltoid  at  its  attach- 
ment; exposes  the  posterior  part  of  the  capsule  from  above,  opens  it  in 
the  sagittal  line  between  the  tendons  of  the  supraspinatus  and  infra- 
spinatus to  about  the  middle  of  the  greater  tuberosity,  and  divides  the 
overlying  soft  parts  to  the  same  extent.  In  the  angular  incision  of 
Kocher  (see  page  106)  the  longitudinal  division  of  the  deltoid  is  avoided; 
the  periosteum  of  the  neck  of  the  scapula  is  incised  and  separated  with 
the  capsule  and  biceps  tendon  from  the  bone.  The  edges  of  the  wound 
are  drawn  well  apart  and  the  bone  sawed  through  with  the  pointed  or 
Gigli  saw.  The  wound  is  closed  except  for  drainage  at  the  lower  angle. 
By  Vogt's  method  the  entire  anterior  and  outer  portion  of  the  deltoid 
are  uninjured;  the  joint  is  approached  from  behind  through  a  simple 
transverse  incision  running  from  the  posterior  border  of  the  acromion 
along  the  lower  border  of  the  spine. 


INTERSCAPULOTHORACIC   AMPUTATION  OF    THE  SHOULDER. 

The  simultaneous  removal  of  the  upper  extremity  and  the  shoulder 
is  preferable  in  many  instances  to  exarticulation,  now  that  it  is  pos- 
sible to  avoid  the  chief  dangers  of  the  operation,  namely,  hemorrhage 
and  entrance  of  air  into  the  veins.  The  most  frequent  indication  is 
malignant  neoplasm,  especially  when  it  involves  the  upper  end  of  the 
humerus,  the  joint,  and  the  surrounding  muscles  or  the  axillary  glands. 
Berger  believes  the  operation  is  indicated  for  all  malignant  tumors  of 


JNTEBSCAPULOTlIoll.U  IC  AMPUTATION  OF  siioULDER.     H3 

the  upper  end  of  the  humerus,  as  the  chances  are  better  if  the  radical 

operation  is  done  at  the  outset  and  not  after  other  operations.  Its 
indication  for  sarcoma  of  the  humerus  lias  been  determined  accurately 
by  Xasse's  histological  demonstration  of  the  tendency  to  metastasis 
in  the  muscles,  hence  the  necessity  of  removing  all  the  muscles  of  the 
arm  leading  to  the  thorax.  It  is  also  indicated  for  tumors  of  the  scapula 
which  have  involved  the  muscles,  the  axilla,  or  soft  parts,  and  which  are 

Fig.  68. 


Interscapulothoracic  amputation.  a.  transversal  is  colli  artery;  6,  omohyoid;  c,  9erratus 
anticus;  d,  trapezius;  e,  subscapulars;  /.  deltoid;  g,  coracoid  process;  h  and  n,  pectoralis 
minor;  i,  biceps;  k  and  o,  pectoralis  major;  /,  median  nerve;  m,  p,  q,  axillary  artery  and  vein; 
dotted  liDe  ( ),  posterior  incision.     (Kocher.) 


beyond  the  compass  of  total  resection  of  the  scapula.  In  carcinoma  of 
the  breast  with  extensive  involvement  of  the  axilla  or  of  the  arm,  the 
operation  is  justifiable  in  the  attempt  to  save  life.  It  is  indicated  further 
in  severe  injuries,  severe  compound  fracture  of  the  scapula  with 
extensive  laceration  of  the  soft  parts  and  destruction  or  crushing  of  the 
upper  extremity;  in  evulsion  of  the  arm  by  machine  accidents,  railroad 
accidents,  etc.  Also  destruction  of  the  shoulder  by  heavy  ordnance  or 
severe  burns  and  charring  of  the  upper  arm  and  shoulder  may  necessitate 
Vol.  III.— S 


1X4  OPERA  TIONS  ON  THE  SHO  ULDER. 

amputation,  as  in  a  case  of  v.  Bergmann's.  The  operation  is  counter- 
indicated  by  an  unfavorable  general  condition;  by  infiltration  of  the  wall 
of  the  thorax  through  the  attached  muscles;  by  extensive  dissemination 
of  the  disease  in  the  skin  and  subcutaneous  tissue  and  in  the  glands  of 
the  supraclavicular  fossa,  and  above  all  by  general  metastasis.  In  trau- 
matic cases  with  severe  shock  the  operation  is  delayed  or  the  exposed 
vessels  merely  ligated,  as,  for  example,  in  total  evulsion  of  the  arm.  If 
the  hemorrhage  is  severe,  the  shock  must  be  disregarded  and  its  dangers 
combated  by  infusion. 

In  the  technic  prevention  of  hemorrhage  is  of  first  importance.  Simple 
digital  compression  of  the  subclavian  artery  in  the  supraclavicular  fossa 
is  uncertain,  and  the  danger  of  air  entering  the  vein  must  be  avoided; 
consequently  previous  ligation  of  the  subclavian  artery  and  vein  by 
resection  of  the  middle  portion  of  the  clavicle,  as  first  employed  by 
Langenbeck  in  1860,  is  the  most  reliable  procedure.  To  Berger  is  due 
the  credit  of  having  elaborated  the  important  details  of  the  operation 
as  published  in  his  monograph  in  1886.  The  various  modifications  pre- 
ferred by  different  operators  are  not  essential ;  the  following  description 
is  the  one  given  by  Kocher  and  is  practically  the  same  as  Berger's: 

The  incision  begins  at  the  sternal  end  of  the  clavicle,  runs  to  the 
acromion,  and  is  later  completed  by  an  incision  running  downward  and 
forward  to  the  axilla  and  uniting  at  this  point  with  the  posterior  limb 
running  from  the  acromion — Kocher's  lancet  incision,  dotted  line. 
(Fig.  68.)  Extensive  injury  of  the  skin  or  its  involvement  by  tumors  will 
demand  various  modifications  of  this  incision.  The  first  longitudinal 
incision  divides  the  periosteum  of  the  clavicle;  the  bone  is  divided  at 
its  inner  third,  pulled  outward,  and  freed  from  the  subclavius  and  trape- 
zius. The  subclavius  is  separated  in  the  direction  of  its  fibres,  the  fascia 
incised,  and  the  subclavian  vessels  and  the  plexus  exposed.  The  indi- 
vidual nerves  are  divided,  the  vessels  tied  in  two  places  and  divided. 
To  avoid  hemorrhage,  it  is  also  advisable  to  ligate  the  branches  of  the 
thyroid  axis  running  outward  over  the  scaleni — ascending  and  superficial 
cervical  and  suprascapular — and  the  transversalis  colli  artery.  The 
incision  is  now  lengthened  downward  and  forward  toward  the  axilla,  the 
pectoralis  major  and  minor  divided  layer  by  layer,  and  all  vessels 
clamped  immediately.  The  axillary  fat  and  glands  are  removed,  the 
latissimus  divided  at  the  posterior  edge  of  the  axilla,  and  the  entire 
anterior  surface  of  the  scapula  made  accessible  by  turning  back  the 
shoulder.  At  the  inner  border  the  levator  scapulae,  serratus  anticus,  and 
the  rhomboids  are  divided  from  above  downward;  the  inner  border  of 
the  scapula  is  then  drawn  forward  and  outward,  the  trapezius  separated 
from  the  spine,  and  the  omohyoid  divided.  The  skin  is  incised  behind, 
as  in  Fig.  68,  and  the  operation  completed. 

The  statistics  of  the  operation  are  fairly  numerous:  Konitzer  gives 
133  cases,  the  majority  of  which  were  for  sarcoma,  with  a  mortality 
of  4  per  cent.  In  46  cases  Berger  experienced  only  2  deaths;  in  14 
cases  operated  on  in  v.  Bergmann's  clinic  only  1  was  fatal,  and  in  this 
the  sarcoma  had  already  invaded  the  vena  cava.     Even  the  more  recent 


INTEBSCAPULOTHOBACIC  AMPUTA  TION  OF  SHO ULDER.     115 

works  show  that  recurrence  is  an  ever  present  possibility,  and  that 
Konitzer's  estimate  of  30  per  cent,  recurrence  is  unfortunately  consider- 
ably below  the  actuality.  Buchanan  (1900)  gives  16  pei  cent,  mor- 
tality among  is  1  cases,  131  of  which  were  for  tumors.  Since  1875  the 
mortality  in  general  is  about  8  per  cent. 


Fig.  69. 


Deformity  after  interscapulothoracic  amputation.     (Powers.) 

The  deformity  is  naturally  very  marked.  (Fig.  69.)  Secondary 
scoliosis  is  rather  frequent.  A  prothesis  is  sometimes  beneficial.  Collin 
constructed  an  apparatus  consisting  of  a  leather  jacket  and  an  artificial 
arm,  the  latter  being  hinged  to  the  jacket  by  means  of  iron  strips  and 
movable  forward,  backward,  and  outward.  An  elastic  band  draws  it 
against  the  side  after  it  is  moved.  The  elbow  is  jointed,  and  the  thumb 
so  constructed  that  it  can  be  approximated  against  the  other  ringers  or 


116 


OPERATIONS  ON  THE  SHOULDER. 


extended  by  means  of  a  catgut  string  running  on  pulleys  obliquely  across 
the  back  of  the  jacket  and  fastened  to  a  band  on  the  other  arm.  The 
apparatus  of  Lucas  Championniere  is  simpler,  consisting  of  a  tight- 
fitting  linen  jacket  with  buckles.    It  is  covered  on  the  affected  side  with 


Deformity  after  interscapulothoracic  amputation.     (Powers.) 

leather,  to  which  the  arm  is  attached;  it  has  no  apparatus  for  the  exten- 
sion of  the  thumb.  By  wearing  such  an  apparatus  the  deformity  is 
concealed,  the  patient  is  able  to  grasp,  hold,  and  carry  light  objects,  and 
can  even  do  special  work;  Berger's  patient  worked  as  a  postman  for 
eighteen  years  afterward. 


CHAPTER   IV. 

MALFORMATIONS  OF  THE  UPFER  ARM. 

Among  the  malformations  of  the  arm  should  he  mentioned  amelia, 
or  complete  absence  of  all  extremities,  in  which  there  are  merely 
small  wart-like  protuberances  or  short  stumps,  whereas  the  trunk  is 
well  formed;  abrachia,  or  absence  of  the  arms;  and  monobrachia,  or 
absence  of  one  arm.  Perobrachia  signifies  a  rudimentary  formation  of 
the  arm;  the  hand  is  often  more  or  less  well  developed  and  projects 
from  the  trunk  like  the  extremity  of  a  seal — phocomelia;  the  malforma- 
tion may  affect  all  four  extremities  or  only  the  upper,  and  is  more 
frequently  bilateral.  "Spontaneous  amputation"  may  affect  the  upper 
arm,  although  less  frequently  than  the  forearm  and  lower  extremity, 
and  is  produced  by  amniotic  bands.  Almost  complete  amputation  has 
been  produced  by  entanglement  in  the  umbilical  cord;  in  certain  instances 
of  spontaneous  amputation  the  stump  was  pointed,  the  bones  covered 
merely  by  cicatricial  tissue  and  very  sensitive.  In  hemimelia,  in  which 
in  contrast  to  phocomelia  the  distal  part  of  the  extremity  is  lacking, 
there  are  usually  small  excrescences  at  the  end  representing  the  rudi- 
mentary fingers.  Individuals  with  such  rudimentary  extremities  often 
learn  to  hold  a  pen  in  the  mouth,  eat  with  their  feet,  and  perform  many 
kinds  of  work'  they  can  do  many  things  with  a  prothesis.  "Congenital 
hypertrophy"  is  less  frequent,  and  usually  affects  the  thicker  portions 
of  the  arm  and  is  accompanied  by  dilatation  of  the  vessels.  Holmes 
refers  such  conditions  to  a  disease  of  the  vascular  system  or  to  processes 
such  as  lead  to  the  development  of  congenital  tumors.  In  some  in- 
stances the  disturbance  was  accompanied  by  thickening  of  the  soft 
parts  similar  to  elephantiasis  or  by  the  formation  of  circumscribed 
lipomata.  According  to  Trelat,  the  hypertrophy  involves  chiefly  the 
muscles  and  bones. 


(117; 


CHAPTER   V. 

INJURIES  OF  THE  UPPER  ARM. 
INJURIES  OF  THE  SOFT  PARTS  OF  THE  UPPER  ARM. 

Ox  account  of  its  exposed  position  and  manifold  uses  the  arm  is 
greatly  subjected  to  external  violence,  and  is  freouentlv  injured  by 
contusions  and  wounds  from  sharp  and  blunt  instruments.  In  contusion 
there  may  be  extensive  subcutaneous  hemorrhage  along  the  entire  arm, 
especially  on  the  inner  side;  tangential  forces  may  produce  more  or  less 
extensive  avulsion  of  the  skin  from  its  substratum  with  or  without 
subcutaneous  extravasation  of  blood  or  lymph.  In  such  instances  the 
skin-pockets  are  not  fully  distended,  the  content  can  be  easily  moved 
about  and  collects  mostly  in  the  dependent  portions.  Fluctuation  in  the 
swelling  is  distinct,  although  soft,  and  often  remains  unchanged  for  a 
long  time.  Compressing  bandages  bring  about  prompt  recovery;  excep- 
tionally suppuration  occurs  and  requires  incision. 

Wounds  from  sharp  instruments  are  not  uncommon  in  the  upper  arm, 
and  involve  skin  and  subcutaneous  tissue  alone  or  also  the  muscles  and 
nerves.  If  the  subcutaneous  veins  bleed  much,  as  sometimes  happens, 
they  must  be  ligated.  Large  clots  should  be  turned  out  of  the  pockets. 
Simultaneous  injuries  of  the  arteries  or  nerves  should  always  be  thought 
of.  In  transverse  or  oblique  wounds  on  the  flexor  surface  of  the  arm  the 
bandage  should  be  applied  with  the  elbow  flexed;  with  the  elbow  ex- 
tended for  wounds  on  the  extensor  surface.  Extensive  injuries  of  the 
skin,  particularly  avulsion  by  machinery,  burns,  anabrosis,  etc.,  may 
be  followed  by  severe  contractures.  Torn  skin-flaps  resulting  from 
machinery  accidents  rarely  heal  even  if  the  pedicle  is  broad,  as  usually 
the  tissues  are  so  badly  damaged  that  gangrene  follows.  It  is  not 
advisable  to  suture  such  flaps  in  place;  the  chances  are  better  if  the 
retention  suture  is  delayed  several  days.  Large  skin  defects  and  sub- 
sequent granulating  surfaces  require  Thiersch  grafts  or  pedunculated 
skin-flaps  brought  over  from  the  shoulder  or  thorax. 

INJURIES  OF  THE  MUSCLES  OF  THE  UPPER  ARM. 

Wounds  of  Muscles. — Incised  wounds  of  the  muscles  are  frequently 
caused  by  scythes,  knives,  and  sabre  duels.  There  is  usually  partial 
division  of  one  or  more  muscles  combined  with  injuries  of  the  nerves 
or  vessels.  The  belly  of  the  muscles  is  seldom  entirely  severed  so  that 
the  ends  retract  in  the  wound.  Although  union  has  been  seen  where 
there  was  marked  separation,  it  is  better  to  suture  the  muscle  in  tiers 
(  US) 


INJURIES  OF  THE  MUSCLES  OF  THE  UPPER  ARM.  \  \\\ 

with  strong  catgut,  preferably  double,  to  prevent  the  sutures  from  tear- 
ing out. 

Hernia. — Hernia  of  the  muscles  sometimes  occurs  in  subcutaneous 
or  other  injuries  from  the  tearing  of  the  fascia,  and  is  recognizable  by 

the  presence  of  a  small  soft  tumor  which  hardens  during  contraction, 
feels  elastic  during  moderate  contraction  of  the  muscle,  and  subsides 
entirely  during  relaxation;  the  vent  in  the  fascia  can  then  be  felt 
plainly.  Such  hernias  produce  little  trouble,  so  that  operation  (suture 
of  fascia)  is  rarely  required. 

Rupture. — Rupture  of  the  muscles  is  more  serious,  and  takes  place 
as  a  subcutaneous,  partial  or  complete  separation  of  individual  muscles 
of  the  arm.  It  is  usually  the  result  of  overexertion,  namely,  of  a 
demand  upon  the  muscle  greater  than  its  strength,  whereby  it  is  torn 
during  contraction.     It  occurs  almost  exclusively  in  men;  exceptionally 

Fig.  71. 


Rupture  of  the  biceps,     (v.  Bruns.) 

in  individuals  with  degenerated  muscles — as  in  alcoholics — or  at  the 
site  of  previous  injury,  as,  for  example,  after  extirpation  of  a  tumor. 
(Ceppi.)  The  biceps  is  most  commonly  affected,  especially  the  long 
head.  In  81  cases  of  muscular  rupture  collected  by  Maydl,  there  were 
18  of  the  biceps.  Loos  recently  collected  66  cases  of  rupture  of  the 
biceps,  of  which  2  were  in  women,  in  connection  with  4  cases  seen  in 
v.  Bruns'  clinic.  Among  56  of  these  cases,  more  fully  described,  there 
were  only  2  of  the  short  head,  1  of  both  heads,  3  of  the  common  belly, 
and  3  of  the  distal  tendon,  in  contrast  to  49  of  the  long  head.  In  the 
ktter  cases  the  tear  was  in  the  upper  tendon  in  10,  at  the  musculo- 
tendinous junction  in  20,  in  the  belly  of  the  muscle  in  17.  Petit  found 
the  tendon  of  the  long  head  ruptured  in  only  43  of  83  cases. 

Etiology. — The  cause  is  usually  overexertion,  violent  overstretching  of 
the  contracted  muscle,  as  in  lifting  a  heavy  weight  or  throwing  heavy 


120  INJURIES  OF  THE  UPPER  ARM. 

bodies,  as  in  bowling,  etc.  The  rupture  may  result  from  the  weight  of 
the  body,  as  in  a  case  seen  by  Thiem  of  a  man  who  was  left  suspended 
in  the  air  by  the  breaking  of  a  scaffold  and  then  fell.  Many  regard 
inco-ordinated  contraction  of  the  muscle  as  a  cause;  in  such  cases  the 
passive  stretching  of  an  actively  contracted  muscle,  possibly  in  its  mar- 
ginal bundles,  cannot  be  excluded.  Weber  states  that  the  coraco- 
brachialis  and  short  head  of  the  biceps  of  washerwomen  are  frequently 
torn  while  wringing  clothes.  The  injury  is  accompanied  sometimes  by 
a  distinct  snap,  sudden  pain,  and  corresponding  loss  of  function. 

Symptoms.  —The  deformity  of  the  muscle  is  usually  recognizable  dur- 
ing contraction;  there  is  a  depression  admitting  the  finger.  In  transverse 
ruptures  in  the  upper  part  the  approximation  of  the  belly  of  the  muscle 
to  the  elbow  is  noticeable  compared  with  the  other  side.  In  ruptures 
of  the  lower  half  the  upper  end  is  drawn  upward  and  forms  a  soft 
swelling  that  sometimes  feels  like  a  cyst.  The  muscle  can  be  stroked 
back  into  its  normal  position  with  slight  pressure.  There  is  usually  local 
hemorrhage  spreading  out  into  the  surrounding  tissues.  Flexion  of  the 
arm  is  weaker  in  supination  than  in  pronation.  By  the  action  of  the 
brachialis  the  arm  can  be  bent  slowly  but  without  power. 

Diagnosis. — The  diagnosis  of  rupture  of  the  biceps  depends  upon  its 
sudden  onset  with  pain,  the  deformity  of  the  biceps,  the  evident  cleft 
in  the  substance  of  the  muscle,  the  increase  of  the  same  during  exten- 
sion of  the  forearm,  and  upon  the  impaired  flexion  with  the  forearm 
supinated.  With  rupture  of  the  tendon  of  the  long  head  there  is 
forward  and  inward  partial  dislocation  of  the  humerus. 

Rupture  of  the  triceps,  although  more  rare,  has  been  seen  as  the 
result  of  a  fall  upon  the  flexed  arm,  of  slipping,  and  of  falling 
while  holding  a  basket.  Rupture  and  tearing  of  the  brachialis  are  of 
rather  frequent  occurrence  in  injuries  of  the  elbow — fractures  of  the 
lower  end  of  the  humerus,  sprains,  etc. — and  are  evidenced  by  marked 
ecchymosis  on  the  front  and  side  of  the  forearm  and  lower  third  of  the 
upper  arm. 

Prognosis. — The  prognosis  is  naturally  more  favorable  in  partial 
than  in  complete  ruptures.  In  the  majority  of  cases  the  function  is 
fully  restored,  although  persistent  disability  has  been  observed.  If 
improperly  treated,  union  may  be  by  broad  bridges  of  fibrous  tissue, 
and  the  muscle  become  hour-glass  shaped.  Thiem  estimates  the 
annuity  of  cases  with  impairment  of  flexion  at  from  10  to  20  per  cent. 

Treatment. — Treatment  consists  in  approximating  the  surfaces  by 
applving  a  flannel  bandage — propulsive  bandage — or  adhesive  strips, 
and  immobilizing  in  the  position  of  greatest  relaxation.  If  the  separation 
is  marked,  and  particularly  if  it  affects  the  tendinous  portion,  incision 
and  suture  are  advisable. 

Besides  rupture  of  the  muscle,  various  other  less  noticeable  injuries 
of  a  traumatic  nature  occur  which  are  recognized  chiefly  by  their 
sequela?;  avulsion  of  the  muscle  with  its  periosteum  may  give  rise  to  a 
process  of  ossification  extending  from  the  point  of  rupture  over  entire 


INJURIES  OF  THE  VESSELS  OF  THE  UPPER  ARM.  121 

groups  <>!'  muscles.  In  severe  contusion  of  the  arm  produced  by 
crushing  between  two  rollers,  as  happens  frequently  in  spinning  and 

similar  industries,  the  entire  muscular  parenchyma  can  be  reduced  to  a 
pulp  beneath  the  intact  skin,  so  that  it  is  later  absorbed  and  replaced 
by  cicatricial  tissue,  analogous  to  the  process  observed  in  ischemic 
degeneration. 


INJURIES  OF  THE  VESSELS  OF  THE  UPPER  ARM. 

The  brachial  artery  may  be  injured  by  puncture,  incised,  stab  or 
gunshot-wounds,  frequently  in  connection  with  injuries  of  the  muscles, 
nerves  or  humerus.  In  warfare  gunshot-wounds  of  the  brachial  artery 
are  rather  common.  In  American  wars  they  represented  18  per  cent., 
and  in  the  Russo-Turkish  War  25  per  cent,  of  all  vascular  injuries. 

Diagnosis. — The  diagnosis  is  simple  in  the  presence  of  primary  or 
secondary  hemorrhage;  in  their  absence  the  author  relies  chiefly  upon 
the  situation  and  direction  of  the  wound,  absence  of  pulsation  in  the 
distal  part  of  the  artery,  coldness  of  the  extremity,  and  in  case  of  partial 
laceration  of  the  artery  he  depends  especially  upon  the  oscultatory 
phenomena. 

Prognosis. — The  prognosis  is  doubtful,  as  under  circumstances  there 
is  danger  of  gangrene  and  sepsis  or  of  the  formation  of  a  false  aneurism; 
simultaneous  injury  of  the  veins  and  nerves  makes  it  much  less  favor- 
able. 

Treatment. — The  same  general  principles  apply  as  described  pre- 
viously under  injuries  of  the  vessels  at  a  higher  level;  the  possibilities 
here,  however,  of  first  aid  and  future  operation  are  much  better  than 
in  the  axilla  by  reason  of  the  accessibility  of  the  arteries  for  digital 
compression  and  the  elastic  bandage.  The  danger  of  paralysis  is  to  be 
remembered  in  applying  the  tourniquet.  The  rule  is  to  find  and  double 
ligate  the  brachial  at  the  site  of  injury;  ligation  above  the  exit  of  the 
profunda  greatly  increases  the  danger  of  gangrene,  and  should  be 
employed  only  when  a  phlegmonous  infection  of  the  wound  presents 
the  danger  of  septic  secondary  hemorrhage.  If  the  artery  is  merely 
punctured,  it  may  be  possible  to  suture  it.  Doerfler  reports  a  case  in 
which  the  edges  of  the  wound  forming  flaps  on  either  side  of  a  half- 
severed  artery  were  sutured  successfully  with  four  stitches.  In  simul- 
taneous injury  of  the  brachial  artery  and  vein  an  arteriovenous  aneurism 
may  develop. 

Subcutaneous  Injuries  of  the  Brachial  Artery. — It  is  very  seldom 
that  severe  contusion  produces  rupture  of  the  brachial  artery.  Pautier 
saw  a  case  of  this  sort,  leading  to  gangrene  and  amputation,  in  a  driver 
who,  while  intoxicated,  fell  off  a  heavy  wagon,  the  wheel  passing  over 
the  middle  of  his  arm.  Rupture  of  the  inner  and  middle  coats  happens 
more  often  from  severe  crushing  forces  (run-over,  buffer,  and  machinery 
accidents);  at  times  it  is  followed  by  the  formation  of  an  aneurism,  or 
by  thrombosis  and  threatening  gangrene,  or  by  actual  gangrene  of  the 


122  INJURIES  OF  THE  UPPER  ARM. 

hand  and  forearm.  The  rupture  may  be  due  to  stretching  of  the  coats 
where  the  trauma  acts  solely  upon  the  forearm.  In  the  majority  of 
cases  there  is  also  severe  contusion  and  laceration  of  the  muscles,  or 
fracture.  Such  cases  may  have  a  medico-legal  bearing  in  that  the 
gangrene  is  easily  referred  to  an  apparently  constricting  bandage. 
Secondary  disturbances — ischsemic  muscular  paralyses — may  follow  such 
subcutaneous  injuries  of  the  vessels  of  the  arm. 


INJURIES  OF  THE  NERVES  OF  THE  UPPER  ARM. 

On  account  of  their  superficial  position  the  nerves  of  the  upper  arm 
are  greatly  exposed  to  injury,  such  as  incised,  penetrating,  and  stab- 
wounds;  as  from  falling  upon  glass  utensils,  sharp-edged  sheets  of  tin, 
iron,  etc.  They  are  occasionally  damaged  in  operations  if  they  have 
become  enclosed  in  cicatricial  tissue  or  forced  out  of  their  normal  posi- 
tion; further,  they  may  be  empaled  by  sharp  fragments  in  fractures. 
Blunt  division  and  laceration  of  the  nerves  occur  in  gunshot  and 
machinery  injuries,  especially  in  belting  accidents.  The  division  of  the 
nerve  may  be  complete  or  partial,  clean  cut  and  smooth,  or  frayed, 
oblique  or  transverse.  The  retraction  of  the  stumps  is  usually  slight 
except  in  old  cases  of  division  or  laceration  with  loss  of  substance. 

Symptoms.  — The  symptoms  are  loss  of  motor  and  sensory  function  of 
the  divided  nerve.  The  sensory  area  is  often  supplied  simultaneously 
by  different  nerves,  so  that  the  disturbance  produced  by  the  division  of 
the  nerve  often  affects  only  a  portion  of  the  area.  The  faradic  and 
galvanic  irritability  of  the  divided  nerve  diminishes  rapidly  and  soon 
ceases;  degeneration  is  more  or  less  pronounced  and  rapid. 

Course. — The  course  varies  greatly  in  individual  cases.  Union  of 
nerves  by  primary  intention,  namely,  the  immediate  reunion  of  the  axis- 
cylinders  of  the  divided  ends,  even  if  they  are  accurately  apposed,  has 
not  been  verified.  Recovery  is  effected  by  regeneration  of  the  axis- 
cylinders  of  the  proximal  stump.  The  peripheral  portion  merely  fur- 
nishes the  path  for  the  new  nerve-formation. 

Prognosis. — The  prognosis  depends  not  only  upon  the  nature  of  the 
division,  the  time  elapsed,  etc.,  but  essentially  upon  the  treatment.  If 
regeneration  occurs,  the  electrical  irritability  returns  gradually  and  sen- 
sation is  restored  before  mobility.  Exceptionally  the  new  fibres  conduct 
motor  impulses  before  they  respond  to  electricity.  Months,  sometimes 
years,  are  required  for  complete  restitution  of  mobility  in  the  case  of  the 
nerves  of  the  upper  arm,  whereas  the  first  sign  of  returning  motor 
function  is  usually  evident  in  the  third  or  fourth  week.  The  more  recent 
the  injury  and  the  quicker  the  union  of  the  stumps,  the  better  the 
outlook.  Primary  union  particularly  improves  the  prognosis;  suppura- 
tion, in  addition  to  destroying  the  stumps  of  the  nerve,  may  lead  to  the 
production  of  fibrous  tissue.  Even  in  the  cases  of  primary  suture  with 
favorable  recovery  trophic  disturbances  may  appear  later  or  the  result 
may  be  only  temporary.    At  all  events,  slight  disturbances  often  persist 


INJUR  IKS  OF  THE  NERVES  OF  THE  UPPER  ARM.  123 

in  the  hand.  Division  higher  up  is  less  favorable,  as  the  more  distal 
the  lesion,  the  shorter  is  the  portion  to  undergo  regeneration. 

Treatment. — The  treatmenl  aims  to  establish  the  most  favorable 
conditions  for  regeneration — that  is,  exaet  apposition  of  the  stumps. 
Although  regeneration  doubtless  occurs  without  suture,  the  surgeon's 
dutv  is  to  procure  union  by  primary  suture  if  possible.  Nerve  suture 
is  a  comparatively  recent  operation;  yet  the  statistics,  especially  with 
regard  to  the  arm,  are  fairly  numerous;  and  although  the  justification 
and  indication  of  suture  were  formerly  open  to  discussion,  at  the  present 
time  the  author  regards  it  as  the  duty  of  the  surgeon  to  suture  in  recent 
and  often  in  old  cases.  The  surgeon  should  be  convinced  that  suture 
of  the  divided  nerve  is  indicated  as  much  as  suture  of  the  divided  tendon. 
The  circumstance  that  conduction  is  restored  spontaneously  so  frequently 
after  operative  division  of  the  sensory  nerve  of  the  face  should  not  lead 
to  the  delusion  that  the  same  thing  happens  in  the  peripheral  nerves  in 
the  extremities,  as  in  the  latter  there  is  usually  retraction  of  the  ends 
and  cicatrization  or  interposition  of  fibrous  tissue  that  arrests  the  func- 
tion permanently.  Failure  to  suture  must  be  regarded  as  an  error,  as 
the  operation  has  proved  successful  and  extremely  beneficial  in  more 
than  two-thirds  of  the  cases. 

Special  measures  are  necessary  -for  defects  in  the  nerve  preventing 
approximation  of  the  stumps.  If  the  separation  is  slight — 1  to  H  inches 
— union  may  be  obtained  by  stretching.  (M.  Schiiller.)  If  not,  one 
should  not  hesitate  to  resect  a  part  of  the  humerus;  or  if  there  is  a 
fracture  in  the  ease  concerned,  to  shorten  the  ends.  Plastic  operations, 
namely,  the  formation  of  flaps  (suture  a  lambeaux  ou  dedouplement), 
as  for  defects  in  the  tendons  (Xetievant),  are  not  advisable,  as  the 
nerve  is  thus  additionally  injured  and  the  conditions  for  regeneration 
made  just  so  much  more  unfavorable.  Transplantation  of  nerves, 
namely,  implantation  of  sections  of  nerve  from  an  animal  (Gluck, 
Kaufmann,  and  others),  or  a  section  of  spinal  cord  (Robson),  is  more 
experimental  than  practical.  Vanlair's  tubulization  method  furnishes 
conditions  which  favor  regeneration;  a  decalcified  sterile  tube  of  bone 
(Lotheissen  uses  a  tube  of  formalin  gelatin,  Payr  one  of  magnesium) 
is  used,  into  which  the  stumps  are  fastened;  its  value  has  been  verified 
by  Socin  and  others.  For  large  defects  nerve-grafting  should  be 
considered;  the  peripheral  stump  is  implanted  in  another  nerve. 
Depres  implanted  the  distal  stump  of  a  torn  median  nerve  between  the 
separated  fibres  of  the  ulnar.  Kolliker  regarded  this  procedure  as  an 
unfortunate  modification,  as  the  healthy  nerve  is  thus  injured,  and  if  the 
freshening  of  the  fibres  is  insufficient  they  will  not  regenerate.  These 
various  procedures,  employed  chiefly  by  English  surgeons  (Harvey, 
Galbraith,  Reed)  under  the  name  "neural  infixation,"  require  further 
trial  before  they  can  be  rejected. 

If  some  time  has  elapsed  since  the  injury,  secondary  suture  is  indi- 
cated if  any  considerable  functional  disturbance  still  exists.  The  results 
of  secondary  suture  as  reported  in  the  literature  are  not  less  favorable 
than  those  of  the  primary — about  75  per  cent,  of  recoveries.     If  the  site 


124  INJURIES  OF  THE  UPPER  ARM. 

of  division  is  surrounded  by  much  cicatricial  tissue,  secondary  suture  is 
often  difficult.  The  area  is  best  exposed  by  following  along  the  nerve 
from  above  and  below.  It  is  important  to  remove  entirely  the  cicatrized 
and  degenerated  parts  of  the  stumps,  and  to  protect  the  nerve  against 
the  pressure  of  a  new  cicatrix  by  shifting  it  into  healthy  tissue  or  sheathing 
it  by  tubulization.  P.  Bruns  gives  an  important  modification  to  avoid 
extensive  resection  and  shortening  of  the  nerve.  In  suturing  the  radial 
nerve  secondarily  he  divided  longitudinally  the  cicatricial  band  uniting 
the  stumps,  folded  the  divisions  on  each  other  laterally,  and  sutured 
them,  thus  approximating  the  stumps.  If  the  proximal  stump  is  club- 
shaped,  v.  Bruns  recommends  dividing  it  longitudinally  up  to  normal 
nerve-fibre,  tapering  the  distal  stump,  and  inserting  and  suturing  it  in 
the  cleft;  the  contact  surface  and  security  of  the  suture  are  thus  increased. 

The  after-treatment  consists  in  immobilization  for  two  or  three  weeks; 
later,  massage  and  electricity  to  stimulate  the  atrophied  muscles. 

Pressure-paralysis  of  the  nerves  of  the  arm  is  not  uncommon  on  account 
of  their  superficial  position.  Such  paralysis  occurs  repeatedly  after 
application  of  the  Esmarch  bandage;  during  operation  from  pressure 
against  the  edge  of  the  operating-table;  in  sleeping  in  a  chair,  from 
the  arm  resting  against  the  chair-arm.  Pressure-paralysis  occurring 
during  the  union  of  fractures  will  be  discussed  later.  Various  occupa- 
tional injuries  often  produce  paralyses  by  compression  of  the  nerve. 
Bachon  describes  a  typical  paralysis  in  the  water-carriers  of  Rennes; 
they  carry  the  water  in  a  large  jar,  the  bottom  of  which  is  supported 
against  the  lower  front  part  of  the  trunk,  the  arm  being  thrust  through 
the  handle  and  the  jar  pressed  against  the  chest.  In  this  way  pressure 
is  brought  to  bear  upon  the  outer  posterior  surface  of  the  arm,  obliquely 
across  the  musculospiral,  so  that  it  is  not  surprising  that  the  nerve  is 
compressed. 

Besides  pressure,  various  injuries  affect  the  nerves  of  the  upper  arm 
(contusions,  tears,  displacement  of  the  nerve),  producing  temporary  dis- 
turbances (tingling,  numbness,  and  paretic  conditions)  or  severe  neural- 
gias, spasms,  or  paralysis.  The  so-called  neuralgia  of  venesection  was 
formerly  a  well-known  occurrence.  (Bell,  Brodie,  Pirogoff.)  Neuritic 
disturbances  and  severe  pains  are  sometimes  caused  by  cicatricial  ad- 
hesions and  fibrous  tissue  about  the  nerve — as  occasionally  happens 
after  phlegmon — and  by  exostoses.  In  such  cases  neurolysis,  namely, 
the  freeing  of  the  nerve  from  the  compressing  cicatrix  or  fibrous  tissue, 
may  be  indicated.  The  formation  of  new  adhesions  should  be  prevented 
during  the  process  of  healing;  there  are  many  places — for  example,  the 
ulnar  groove — where  there  is  great  danger  of  renewed  compression  follow- 
ing the  operation,  whereas  between  the  muscles  the  conditions  are  much 
more  favorable,  as  the  muscular  action  mobilizes  the  cicatrix.  It  is 
generally  a  good  plan  to  stretch  the  nerve  moderately  after  separating  it 
from  its  adhesions. 

Injuries  of  the  Musculospiral  Nerve, — From  the  axilla  the  musculo- 
spiral nerve  runs  between  the  long  and  inner  head  of  the  triceps  on  the 
posterior  surface  of  the  humerus,  forms  a  spiral  about  the  humerus, 


INJURIES  OF  THE  NERVES  OE  THE  UPPER  ABM,  125 

gives  off  muscular  branches  at  the  junction  of  the  lower  and  middle 
thirds  on  the  outer  side,  and  enters  the  elbow  to  the  outer  side  of  the 
radial  artery  covered  by  the  supinator  longus,  to  course  down  the  radial 
side  of  the  forearm.  It  supplies  the  triceps,  supinator  longus  and  hrevis, 
extensor  carpi  radialis  longus  and  hrevis,  extensor  communis,  extensor 
carpi  ulnaris,  extensor  pollicis  longus  and  hrevis,  and  the  extensor 
digitis  indicis.  It  is  the  sensory  nerve  of  the  dorsum  of  the  hand  and 
fingers,  except  the  little  finger. 

Musculospiral  paralysis  is  the  most  frequent  and  most  important  of 
the  paralyses  of  the  brachial  plexus.  In  its  spiral  course  around  the 
outer  side  of  the  humerus  the  nerve  is  exposed  to  incised,  puncture, 
and  stab-wounds,  and  is  very  liable  to  injury  in  fractures,  as  will  be 
discussed  under  complications  of  fracture  of  the  humerus.  Gunshot- 
wounds  are  unusual. 

Symptoms. — The  first  symptom  of  musculospiral  paralysis  is  inability 
to  extend  the  hand  and  fingers.  The  hand  hangs  in  characteristic  pro- 
nation and  flexion — drop-wrist.  The  flexors  soon  prevail,  so  that  as  a 
rule  a  flexion  contracture  develops  very  promptly.  The  muscles  supplied 
by  the  nerve  atrophy;  extension  of  the  last  two  phalanges  by  the  interossei 
— supplied  by  the  deep  branch  of  the  ulnar — is  still  possible,  but  exten- 
sion of  the  basal  phalanges  is  lost,  so  that  the  fingers  are  flexed  at  the 
metacarpophalangeal  joints.  Anaesthesia  on  the  dorsum  is  more  or  less 
extensive,  but  may  be  slight  on  account  of  the  anastomosis  of  the  nerves 
and  the  so-called  "supplementary  function."  In  an  old  case  Rusch  found 
an  anaesthetic  area  on  the  dorsum  only  Jt  inch  in  diameter.  Exceptionally, 
trophic  disturbances  may  supervene  in  old  cases.  From  these  symptoms 
the  diagnosis  is  simple.  In  recent  injuries,  particularly  fractures  of  the 
humerus,  one  should  always  test  the  condition  of  the  nerve. 

Treatment. — Suture  of  the  nerve  gives  good  results  even  in  cases  of 
long  standing.  In  comparison  with  suture  of  other  nerves,  it  gives  by 
far  the  best  prognosis — 93  per  cent,  recoveries — not  only  with  regard  to 
the  return  of  conduction,  but  also  the  degree  of  recovery.  Kramer  gives 
4  failures  in  42  cases  of  suture  of  the  musculospiral,  12  failures  in  50 
of  the  median,  and  8  in  32  of  the  ulnar.  There  were  32  recoveries  in 
35  operations  for  compression  of  the  nerve,  among  which  there  were  2 
resections.  Busch  reports  a  successful  secondary  suture  four  months 
after  the  injury,  Sick  the  same  six  months  after,  Nussbaum  nine  months 
after,  and  Esmarch  sixteen  months  after.  In  1  instance  in  which  it  was 
impossible  to  unite  the  stumps  by  suture,  Sick  obtained  a  useful  hand 
by  suturing  a  bridge  from  the  median  to  the  distal  stump  of  the  musculo- 
spiral. If  the  first  operation  is  not  successful,  all  hopes  should  not  be 
given  up,  as  in  many  instances  conduction  is  prevented  by  fibrous 
union,  etc.,  and  the  paralysis  overcome  only  by  a  second  operation. 
There  are  always  some  cases  which  cannot  be  helped  by  operation. 
Thiem  estimates  a  45  to  50  per  cent,  accident  annuity  for  such  incurable 
paralysis. 

Formerly,  apparatus  was  the  sole  aid  for  such  incurable  cases,  the 
extensor  paralysis  of  the  hand  and  fingers  being  more  or  less  overcome 


126 


INJURIES  OF  THE  UPPER  ARM. 


by  means  of  elastic  bands  or  springs.  Good  results  are  obtained  at  the 
present  time  by  tendon-transplantation;  Franke  attests  its  particular 
value  in  musculospiral  paralysis.  He  holds  the  hand  mechanically  in 
extension  by  shortening  the  tendon  of  the  extensor  carpi  radialis  and 
restores  the  extensibility  of  the  fingers  by  transplanting  a  flexor  tendon 
— for  example,  the  flexor  carpi  ulnaris,  which  is  easily  drawn  over  to 
the  extensor  surface — into  the  tendons  of  the  extensor  communis.  Active 
extension  of  the  thumb  can  be  obtained  by  transplanting  half  of  the 
tendon  of  the  flexor  carpi  radialis  into  the  tendon  of  the  long  extensor 
of  the  thumb,  the  flexor  carpi  radialis  being  meanwhile  stretched  as 
tight  as  possible 

Fig.  72. 


Deformity  from  paralysis  of  the  median  nerve  (ape-hand). 


Injuries  of  the  Median  Nerve. — The  median  nerve  is  not  infre- 
quently divided  in  the  upper  arm  by  blunt  or  sharp  violence,  and  is 
occasionally  stretched  or  torn  in  fractures  or  by  the  projecting  end  of 
the  humerus  in  posterior  dislocation  of  the  forearm.  According  to 
Fischer,  the  median  nerve  was  involved  49  times  in  189  gunshot  injuries 
of  the  nerves  of  the  upper  extremities. 

Symptoms. — As  the  median  nerve  supplies  the  pronator  teres  and 
quadratus,  the  flexor  muscles  of  the  forearm  (excepting  the  flexor  carpi 


INJURIES  OF  THE  NERVES  OF  THE  UPPER  ARM. 


127 


Fig.  73. 


ulnaris  and  the  ulnar  part  of  the  flexor  profundus),  the  muscles  of  the 
ball  of  the  thumb  (except  the  inner  head  of  the  flexor  pollicis  brevis), 
and  is  the  sensory  nerve  of  the  radial  half  of  the  palm,  division  of  the 
nerve  is  manifested  chiefly  by  loss  of  flexion  of  the  hand  and  fingers, 
inability  to  appose  the  thumb,  and  by  anaesthesia  of  the  larger  part  of 
the  flexor  surface  of  the  forearm  and  hand.  If  the  paralysis  persists, 
there  is  atrophy  of  the  flexor  side  of  the  forearm  and  of  the  hall  of  the 
thumb.  By  contraction  of  the  extensors  the  thumb  is  abducted  and 
extended — ape-hand.     (Fig.  72.) 

Treatment. — Suture  of  the  median  nerve,  primary  or  secondary,  is  a 
fairly  frequent  operation.  As  to  its  prognosis  compared  to  suture  of 
the  musculospiral,  see  page  125.  v.  Brims  sutured  the  median  success- 
fully one  year  and  nine  months  after  injury. 

Injuries  of  the  Ulnar  Nerve.— The  ulnar  nerve  is  usually  injured  at 
the  elbow,  rarely  in  the  upper  arm;  it  may  be  damaged  in  fracture, 
especially  oblique  fracture  of  the  con- 
dyles. According  to  Fischer,  the  nerve 
was  injured  3<S  times  in  1S9  gunshot- 
injuries  of  the  nerves  of  the  upper  ex- 
tremity. 

The  ulnar  supplies  the  flexor  carpi 
ulnaris,  part  of  the  flexor  profundus, 
the  adductor  pollicis  brevis,  the  muscles 
of  the  ball  of  the  little  finger,  the  inner 
lumbricales,  the  palmaris  brevis,  and 
the  interossei,  and  is  the  sensory  nerve 
of  the  flexor  surface  of  the  fifth  and 
outer  half  of  the  ring  finger.  Paralysis 
is  evidenced  by  loss  of  extension  of  the 
distal  phalanges,  by  inability  to  abduct 
the  fingers,  and  by  loss  of  motion  of  the 
little  finger  and  of  flexion  of  the  basal 
phalanges.  Persistence  of  the  paralysis 
produces  a  typical  contracture  position 
— claw-hand  (Fig.  73) — characterized 
chiefly  by  atrophy  of  the  interossei,  of 
the  hypothenar,  and  partly  of  the  thenar  eminence,  and  by  the  claw 
position  of  the  fingers.  In  old  cases  of  ulnar  paralysis  there  may  be 
trophic  disturbances,  ulceration,  changes  in  nail-growth,  etc.,  particu- 
larly affecting  the  little  finger.  (Fig.  73.)  The  little  finger  sometimes 
remains  atrophic  and  flexed  after  successful  suture.  Neuralgia  of  the 
ulnar  from  cicatricial  adhesions  following  inflammations,  gunshot- 
wounds  or  fractures,  may  sometimes  require  operative  treatment  in  the 
form  of  neurolysis — the  freeing  of  the  nerve — and  usually  at  the  elbow. 
(See  Injuries  of  the  Elbow.) 


\ 


Deformity  from  paralysis  of  the  ulnar 
nerve  (claw-band). 


128  INJURIES  OF  THE  UPPER  ARM. 

FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS. 

Fractures  of  the  shaft,  namely,  between  the  attachment  of  the  pec- 
toralis  major  and  the  origin  of  the  supinator  longus,  belong  to  the  most 
frequent  fractures — according  to  v.  Bruns,  5  per  cent,  of  all  fractures; 
according  to  Riethus,  53  per  cent,  of  fractures  of  the  humerus.  Incom- 
plete fracture,  infraction,  is  rare  and  occurs  only  in  childhood.  Complete 
fracture  is  usually  oblique,  and  most  frequently  from  above  downward, 
forward,  and  inward.  Transverse  fracture  is  rare,  longitudinal  fracture 
more  so.  One  sees  occasionally  a  bow  fracture  with  a  wedge-shaped 
fragment,  and  torsion  or  spiral  fracture.  Direct  violence  often  produces 
splinter-fractures  or  double  fractures. 

Fig.  74. 


Oblique  fracture  of  the  humerus  above  the  deltoid  insertion,     (v.  Bruns.) 

The  greater  number  of  fractures  are  subcutaneous,  according  to 
Chudowzky,  SO  per  cent.  In  fractures  produced  by  machinery  accidents 
there  is  not  infrequently  a  dislocation  at  the  shoulder  or  elbow  or  simul- 
taneous fracture  of  the  forearm,  the  hand,  etc. 

Etiology. — It  is  known  that  the  shaft  may  be  broken  in  utero  or  during 
delivery  in  freeing  the  arm.  The  common  cause  is  direct  violence,  such 
as  a  fall  against  the  edge  of  the  stairs,  a  blow,  run-over  accidents,  etc.; 
exceptionally,  indirect  violence,  such  as  a  fall  upon  the  elbow  or  the 
extended  hand;  or  muscular  action,  as  in  fighting,  throwing  a  stone, 
cracking  a  whip,  a  misstroke  in  tennis,  etc.  In  85  cases  of  fracture  by 
muscular  action  collected  by  Gurlt,  57  affected  the  upper  arm.  Spon- 
taneous fracture  may  occur  on  slight  provocation  in  diseases  of  the  bone, 
such  as  a  gumma,  soft  cysts,  or  malignant  neoplasms.    It  is  most  frequent 


FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS. 


129 


in  nervous  diseases,  especially  tabes  and  syringomyelia.  I*.  Bruns  has 
described  fully  the  spontaneous  fractures  accompanying  tabes  and  the 

neuropathic  forms  of  brittleness  and  their  frequency  in  mental  diseases, 
especially  in  paralytics.  The  fracture  was  multiple  in  three-fourths  of 
the  cases — in  one  instance  I  I,  in  another  36  fractures.  The  spontaneous 
fractures  occurring  in  malignant  tumors  may  unite  later. 

Symptoms. — In  the  symptom-complex  of  fractures  of  the  shaft  of  the 
humerus  all  the  signs  known  in  the  general  study  of  fractures  are  usually 
found  united  in  a  typical  manner.  Although  there  may  he  little  notice- 
able displacement  as  the  arm  hangs  at  the  side,  the  attempt  to  lift  the 

Fig.  7(i. 


■:*  \ 


Fig.  75. — Compound  transverse  fracture  of  the  humerus  with  three  large  serrations,  due  to  fall 
from  horse,     (v.  Bruns.) 

Fig.  70. — Compound  comminuted  fracture  of  the  humerus,  united  by  weak  bridge  of  callus  after 
discharge  of  numerous  splinters  and  sequestra,     (v.  Bruns.) 


arm  immediately  produces  an  angular  deformity.  Crepitus  is  often 
absent  in  very  oblique  or  spiral  fractures  accompanied  by  impalement 
or  interposition  of  the  muscles.  The  displacement  varies  greatly  accord- 
ing to  the  direction  of  the  violence  and  the  action  of  gravity  resulting 
from  the  position  of  the  arm.  Muscular  traction  is  active  in  fractures 
above  the  insertion  of  the  deltoid,  usually  in  that  the  upper  fragment 
is  drawn  inward  by  the  pectoralis  major,  teres  major,  and  latissimus; 
the  lower  fragment  is  drawn  outward  by  the  deltoid.  In  fractures  below 
the  deltoid  insertion  the  upper  fragment  is  displaced  upward  and  out- 
Vol.  III.— 9 


130 


INJURIES  OF  THE  UPPER  ARM. 


ward  by  the  deltoid,  the  lower  drawn  upward  and  backward  by  the 
elastic  retraction  of  the  triceps. 

Diagnosis. — As  a  rule  the  diagnosis  presents  no  difficulties;  the  displace- 
ment and  angular  prominence  of  one  of  the  fragments  are  often  recog- 
nizable on  inspection.  The  .r-ray  is  a  valuable  aid  in  diagnosis,  par- 
ticularly in  giving  without  pain  the  more  accurate  details  of  the  fracture, 
fissures,  tendency  to  displacement,  etc. 

Prognosis. — The  prognosis  is  usually  favorable.  In  the  majority  of 
fractures  union  occurs  in  youth  in  from  twenty-five  to  thirty  days;  in 
adults,  in  from  four  to  five  weeks.  The  average  time  of  union  is  esti- 
mated by  Chudowzky  as  forty-five  days.  Splinter  or  comminuted  frac- 
tures require  longer,  but  union  usually  occurs  even  after  extensive  cast- 
ing off  of  splinters.  (Figs.  75  and  76.)  The  functional  prognosis  in 
the  event  of  much  callus  or  angular  union  is  not  always  favorable.  In 
fractures  of  the  upper  part  of  the  shaft  the  function  of  the  joint,  par- 

Fig.  77. 


Middeldorpfs  triangle  for  fracture  of  the  humerus. 


ticularly  elevation  of  the  arm,  is  often  permanently  impaired.  In  frac- 
tures of  the  lower  end  the  function  of  the  elbow  is  often  impaired  for 
a  long  while,  the  danger  of  stiffness  being  proportional  to  the  proximity 
of  the  fracture  to  the  joint  and  the  persistence  of  any  displacement.  The 
prognosis  is  compromised  further  by  the  relatively  frequent  appearance 
of  radial  paralysis  and  pseudarthrosis. 

As  to  accident-sequelae  and  their  medico-legal  aspect,  Haenel  esti- 
mates that  72  per  cent,  of  the  cases  recover  within  the  time  covered 
by  accident  annuities,  and  the  average  period  necessary  for  full  recovery 
he  places  at  six  and  a  half  months.  Even  multiple  fractures  give  a 
good  prognosis  with  proper  treatment;  Schinzinger  recently  reported  a 
triple  fracture  of  the  humerus  that  healed  without  shortening. 

Treatment. — The  usual  method  of  reduction  is  for  one  assistant  to 
hold  the  shoulder  from  the  other  side;  a  second  assistant  pulls  upon  the 


FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS. 


131 


arm  in  its  long  axis  by  grasping  the  flexed  elbow  above  the  epicondyles, 
while  the  operator  apposes  the  fragments.  If  reposition  is  accurate,  the 
external  epicondyle,  greater  tuberosity,  and  acromion  are  in  line.     If 


Fig.  78. 


Fig.  79. 


Vulpius'  aluminum  splint  with  sliding  cross-pieces. 


muscular    interposition     is     sus-  FlG-  §0- 

pected  from  the  absence  of  crep- 
itus combined  with  free  false 
motion,  it  should  be  overcome  by 
strong  extension  and  lateral  and 
rotary  movements.  If  this  does 
not  succeed,  operation  is  justi- 
fiable; the  fragments  are  then 
fastened  by  suturing  or  nailing. 

A  plaster  splint  is  advisable  for 
uncomplicated  fractures  without 
much  swelling  of  the  soft  parts; 
it  should  enclose  the  shoulder  like 
a  spica  and  extend  to  the  wrist, 
the  forearm  being  semiflexed. 
While  it  is  hardening,  downward 
traction  should  be  exerted  on  the 
end  of  the  humerus.  For  very 
mild  cases  cardboard-strip  splints 
are  sufficient,  as  described  for 
fractures  of  the  upper  end  of  the 
humerus.  All  the  methods  de- 
scribed for  the  latter  fractures 
are  applicable  here  and  do  not 
require  further  discussion.  The 
author  usually  employs  the  ex- 
tension plaster  strip  splints.  (See  page  50. 1  The  old  well-tested 
of  Middeldorpf  (Fig.  77),  either  in  its  original  form  or  with 


Extension  splint  of  adhesive  plaster  strips. 
Hamilton.  \ 


triangle 
various 


232  INJURIES  OF  THE  UPPER  ARM. 

modifications,  is  still  widely  recommended  and  useful.  The  objection  to 
these  ready  apparatus  is  that  one  seldom  has  the  size  on  hand  to  fit  the 
patient.  If  there  is  marked  tendency  to  shortening  and  it  cannot  be 
overcome  by  the  extension-strip  splint,  the  adhesive-plaster  weight- 
extension-method  of  Hamilton  may  be  used  and  the  patient  allowed  to 
be  about  (Fig.  80);  at  night  the  traction  cord  may  be  adjusted  over 
a  pulley  on  the  bed  and  weighted.  Weight  extension  in  the  recumbent 
position  will  be  used  only  when  it  is  necessary  to  confine  the  patient  to 
bed;  contraextension  is  then  obtained  by  means  of  an  axillary  pad  or  a 
cloth  sling  directed  to  the  headpost  on  the  other  side. 


Fracture  of  the  Shaft  Complicated  by  Injuries  of  the  Vessels 

and  Nerves. 

Fracture  Combined  with  Injury  of  the  Vessels.— This  accident 
happens  rather  frequently  and  is  serious.  The  brachial  artery  may  be 
injured  in  an  open  fracture,  or  it  may  be  merely  contused  in  run-over 
accidents,  or  the  inner  coats  of  the  vessel  may  be  torn.  In  other  instances 
it  may  be  pressed  flat,  or  be  closed  by  the  pressure  of  a  fragment,  or  be 
completely  torn  or  impaled  by  a  splinter. 

Symptoms. — Naturally  the  symptoms  vary  greatly  according  as  there 
is  an  open  injury  of  the  artery,  or  subcutaneous  compression,  or  lacera- 
tion.   In  the  latter  case  the  signs  are  those  of  an  aneurism  or  gangrene. 

Prognosis. — The  prognosis  of  an  arterial  lesion  is  always  serious. 
Cases  are  known  in  which  the  arterial  hemorrhage  necessitated  primary 
ligation  and  yet  the  arm  was  preserved;  others  in  which  the  arm  remained 
pulseless  and  cold  for  several  days,  but  was  saved  by  conservative  treat- 
ment and  envelopment  in  warm  dressings.  Even  if  gangrene  is  avoided, 
the  lesion  may  cause  subsequent  ischaemic  muscular  contractures. 

Fracture  Combined  with  Injury  of  the  Nerves.— This  is  of  even 
greater  practical  importance.  Paralysis  of  the  musculospiral  is  fairly 
frequent,  and  in  recent  years  has  been  the  subject  of  many  valuable 
articles.  In  189  injuries  of  the  nerves  complicating  fractures,  v.  Bruns 
found  138  in  the  upper  extremity;  among  these,  77  of  the  musculospiral, 
19  of  the  ulnar,  17  of  the  median.  He  estimates  the  frequency  of 
musculospiral  paralysis  at  S  per  cent.,  whereas  Riethus  in  the  Leipzig 
clinic  found  that  it  constituted  only  4  per  cent.  Injury  of  the  musculo- 
spiral is  most  frequent  in  fracture  of  the  middle  third — 69  per  cent., 
Riethus;  according  to  v.  Bruns,  it  was  52  per  cent,  for  the  middle  third, 
38  per  cent,  for  the  lower  third.  This  is  easily  understood  from  the 
position  of  the  nerve  in  its  spiral  course  around  the  humerus.  Direct 
violence,  such  as  run-over  accidents,  angular  bodies  falling  upon  the 
arm,  etc.,  and  torsion-fractures,  particularly  when  accompanied  by  great 
displacement  of  the  fragments,  as  in  machinery  accidents,  etc.,  are  the 
most  frequent  causes  of  injury  of  the  musculospiral.  Surgeons  distin- 
guish practically:  paralyses  occurring  at  the  time  of  the  fracture  and 
recognized  immediately  afterward — primary  paralysis  of  the  musculo- 


FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS.  l:;:> 

spiral;  and  those  occurring  later — secondary  paralyses  of  the  musculo- 
spiral. 

Primary  Paralysis  of  the  Musculospiral. — Surgeons  distinguish  ana- 
tomically between  the  cases  in  which  the  continuity  of  the  nerve  is 
retained  and  those  in  which  it  is  lost.  The  latter  are  rare;  in  7'.*  cases 
v.  Brims  found  only  3  of  this  sort.  In  the  former  ease  there  may  be 
contusion  of  the  nerve  by  external  violence;  tearing,  or  laceration  by 
dislocated  fragments,  or  the  nerve  may  be  interposed  between  the  frag- 
ments or  impaled  by  a  sharp  splinter.  Even  with  apparent  preservation 
of  continuity  the  nerve-substance  may  be  entirely  crushed  within  the 
neurilemma.  If  there  is  separation  of  continuity,  the  nerve  may  be  torn, 
contused,  cut  off  clean  by  a  sharp  fragment,  especially  in  torsion  fracture, 
or  crushed. 

Symptoms. — The  symptoms  of  musculospiral  injury  vary  according 
to  the  severity  of  the  injury  and  the  nature  of  the  violence.  In  simple 
contusion  there  may  be  sensory  disturbances  and  temporary  paresis; 
usually,  however,  the  characteristic  picture  of  complete  paralysis  is  seen. 
(See  page  125.)  In  injury  of  the  musculospiral  high  up  the  triceps  may 
be  affected,  as  in  a  case  of  high  fracture  seen  by  Middeldorpf.  The 
very  embarrassing  position  in  which  a  surgeon  may  be  placed  by  over- 
looking a  primary  musculospiral  paralysis  can  be  easily  avoided  by 
exercising  proper  care.  It  should  be  made  a  general  rule  without  con- 
dition to  test  the  musculospiral  nerve  in  all  fractures  of  the  shaft  of  the 
humerus,  particularly  those  of  the  middle  and  lower  third.  If  possible, 
the  nature  of  the  injury  causing  the  disturbance  should  also  be  deter- 
mined, a  matter  often  difficult  or  impossible. 

Treatment. — The  treatment  is  expectant.  If  interposition  of  the 
nerve  between  the  fragments  is  suspected  from  the  presence  of  severe 
nerve  pains,  an  attempt  should  be  made  to  free  the  nerve  by  manipu- 
lation— movements  of  extension  and  circumduction — as  effected  by 
Oilier  in  one  instance.  If  this  does  not  succeed,  the  nerve  should  be 
exposed.  If  there  is  no  positive  evidence  of  interposition  the  surgeon 
should  await  consolidation  of  the  fracture,  as  it  is  usually  impossible  to 
determine  whether  there  is  a  paralysis  in  continuity  or  division  of  the 
nerve.  Usually  the  function  is  restored  in  from  one  to  two  months  by 
the  simple  application  of  massage  and  electricity,  and  unnecessary 
operation  is  thus  avoided.  If  restitution  does  not  occur,  secondary 
operation  gives  as  favorable  a  prognosis  as  the  primary  procedure. 

Secondary  Paralysis  of  the  Musculospiral. — The  term  is  only  justified 
when  one  can  be  positive  of  the  integrity  of  the  nerve  directly  after  the 
fracture.  The  cause  of  secondary  paralysis  is  always  pressure.  There 
may  be  constricting  cicatricial  tissue  pressing  the  nerve  against  the  bone 
or  fixing  it  against  a  sharp  projecting  fragment.  There  may  be  an 
abnormal  growth  of  callus  by  which  the  nerve  is  pressed  flat  or  crazed. 
The  callus  may  form  a  tunnel  about  the  nerve  and  compress  it  atone  point 
or  through  its  entire  length.  Exceptionally  the  nerve  may  be  thinned  out 
by  a  bony  spicule  projecting  in  the  bony  canal  or  it  may  be  bent  bayonet- 
shaped;  it  may  be  thinned  and  thickened  in  places  alternately  like  a 


134 


INJURIES  OF  THE  UPPER  ARM. 


Fig.  81. 


pearl  necklace  or  be  enclosed  immovably  in  a  bony  or  fibrous  canal  and 
impaled  by  numerous  spicules.     In  a  single  case  of  Czerny's  the  nerve 

was  bent  at  an  angle  over  a  sharp  fragment 
and  worn  off  by  motion.  In  4  of  his  own 
cases  Schreiber  found  the  nerve  bound  by  a 
cicatrix  against  a  projection  of  callus. 

Symptoms. — In  such  cases  due  to  pressure 
the  signs  of  paralysis  appear  gradually  dur- 
ing or  after  bony  union,  and  are  usually  first 
recognized  at  the  end  of  one  or  two  weeks,  or 
when  the  splint  is  removed  in  the  fourth  to 
sixth  week.  The  sensory  disturbance  is  often 
surprisingly  slight.  The  .r-ray  may  aid  in 
the  diagnosis. 

Prognosis. — The  prognosis  is  favorable 
only  in  the  event  of  operation  and  removal 
of  the  compression  by  freeing  the  nerve  from 
the  cicatricial  tissue  or  bony  canal.  Even  in 
old  cases  hope  should  not  be  relinquished; 
Kennedy  procured  complete  recovery  at  the 
end  of  a  year,  and  Busch  after  sixteen 
months. 

Treatment. — For  the  treatment  the  author 
refers  to  the  chapter  on  Injuries  of  the  Nerves 
of   the  Arm,  and  only  adds  here  that  where 
the   nerve  is  enclosed   in    a    callus    tunnel  it 
Musculospinal  nerve  free i  fn.m    should    be   exposed   distallvand    proximallv 

callus  at  fracture  of  the  humerus  1,1  p    11         1  •      11      1  mi 

i,y  resecting  the  caiius.    (oilier.)     and  then  carefully  chiselled  out.      The  nerve 

is  liable  to  be  cut  by  the  chisel,  as  the  bony 
canal  is  often  very  irregular.  If  after  resection  and  suture  there  is  too 
much  tension,  a  shorter  path  can  be  made  by  chiselling  out  a  deep 
groove  in  the  bone.  If  this  is  not  sufficient,  one  has  to  choose  between 
resection  of  the  humerus  and  a  plastic  operation  on  the  nerve. 


PSEUDARTHROSIS  OF  THE  HUMERUS. 


Delayed  union  and  pseudarthrosis  are  observed  not  infrequently  in 
the  humerus.  In  v.  Brans'  statistics  of  1274  cases  of  ununited  fractures 
there  wrere  376  of  the  humerus;  among  681  authentic  cases  of  pseudar- 
throsis there  were  226  (33  per  cent.)  of  the  humerus.  As  the  frequency 
of  fractures  of  the  humerus  in  general  is  only  15  per  cent.,  this  bone 
shows  the  greatest  tendency  to  pseudarthrosis. 

Etiology. — The  cause  may  be  general  or  local;  wide  separation  of  the 
fragments,  necrosis  of  interposed  splinters  or  of  the  ends  of  the  frag- 
ments, impalement  of  muscle  by  pointed  fragments,  muscular  interpo- 
sition, insufficient  fixation  by  improper  splints.  Exceptionally  a  nerve 
lesion — for  example,  laceration  of  the  musculocutaneous — has  been  held 


rsl'A'DMlTlllloSIS  OF  THE  HUMERUS. 


135 


responsible  (Sneve);  in  aboul  half  the  *IG-  82- 

cases    muscular  interposition  was   at 
fault.     (W.  Meyer.) 

Anatomical  Findings. — There  is 
usually  more  or  less  thick  fibrous 
tissue  between  the  fragments;  the 
latter  often  appear  entirely  without 
reaction  or  are  covered  by  thin  callus 
deposits.  (Fig.  82.)  At  times  the 
fragments  are  found  to  he  necrotic 
or  there  are  necrotic  splinters  lying 
between  them.  Rarely  and  only  after 
long  existence  a  new  joint  may  be 
formed  with  complete  cartilaginous 
disks,  capsule,  etc.  (Fig.  S3);  even 
arthritis  deformans  with  all  its  char- 
acteristics may  develop  in  the  newly 
formed  joint.     (Fig.  84.) 

Diagnosis.  —  The  diagnosis  is  ex- 
tremely simple  from  the  persistence 
of  false  motion  at  the  point  of  frac- 
ture and  the  complete  absence  of 
pain.  The  skiagraph  gives  excellent 
information  in  regard  to  the  details 
of  the  anatomical  condition. 

Prognosis. — The  prognosis  is  doubt- 
ful, as  in  a  certain  number  of  cases 
the  condition  resists  the  most  ener- 
getic treatment,  v.  Brims  estimates  only  56  per  cent,  of  recovery  follow- 
ing resection.  Of  1S7  cases  of  pseudarthrosis  of  the  upper  arm,  98  re- 
covered, 3  were  improved,  73  remained  unimproved,  5  died.  Accord- 
ing to  Midler's  more  recent  statistics  of  48  resections  of  the  long  bones 
for  pseudarthrosis,  there  was  a  positive  result  in  44 — in  5  of  which 
after  secondary  operation — and  no  deaths. 

Treatment. — In  recent  cases  the  milder  measures  should  be  first  em- 
ployed; rubbing  together  of  the  fragments,  massage,  injection  of  irritating 
fluids — tincture  of  iodine,  5  per  cent,  carbolic  acid,  4  to  10  per  cent,  chlo- 
ride of  zinc  solution;  and  if  the  condition  is  more  that  of  delayed  union, 
it  calls  for  exact  fixation  in  a  strip  splint  and  passive  congestion  by 
means  of  an  elastic  bandage,  as  employed  by  Dumreicher.  Further, 
the  surgeon  may  consider  subcutaneous  tearing  of  the  intersubstance; 
electropuncture  or  thermopuncture;  or  he  may  drive  ivory  pegs  into  the 
fragments  or  nail  or  screw  them  together.  For  the  majority  of  cases 
the  surest  method  is  the  removal  of  the  interposed  tissue  and  resection 
with  its  various  modifications.  The  fragments  should  be  freshened,  not 
obliquely  or  transversely  as  was  formerly  done,  but  angularly  or  zigzag, 
in  order  "to  obtain  better  fixation ;  or  the  upper  fragment  may  be  freshened 
and  introduced  into  the  split  lower  fragment.    (Berger.)    In  exposing  the 


Loose  fibrous  pseudarthrosis  of  humerus. 
i  v.  Bruns. 


136 


INJURIES  OF  THE  UPPER  ARM. 


fragments  and  removing  the  interposed  tissue  the  musculospiral  nerve 
should  be  carefully  avoided.    Oilier  reports  a  case  in  which  the  interposed 


Fig.  83. 


Fig.  84. 


Nearthrosis  of  humerus  with  capsule  and 
growth  of  cartilage  on  the  fracture  surfaces. 
(Stanley.) 


Nearthrosis  of  humerus  involved  hy  arth- 
ritis deformans  with  numerous  free  bodies. 
(Honridge.) 


Fig.  85. 


^sN 


tissue  contained  a  splinter  two  and  a  half  inches  long  and  the  musculo- 
spiral nerve;  while  dissecting  layer  by  layer  with  a  bistoury  a  convulsive 

movement  was  observed  and  the  nerve,  dis- 
colored by  blood-pigment,  was  recognized 
with  difficulty  and  isolated.  Interposition  of 
the  musculospiral  may  be  diagnosticated  by 
pressing  the  fragments  together  and  eliciting 
sharp  pains  radiating  to  the  hand. 

After  freshening  the  fragments  they  are 
united  and  fixed.  For  this  purpose  the  vari- 
ous forms  of  bone  suture  may  be  used  (Fig. 
85),  or  the  bones  screwed  together,  or  pegs 
inserted.  Various  methods  have  been  de- 
vised of  inserting  ivory  pegs  or  absorbable 
bone  pegs  in  the  medulla  (Bircher,  v.  Brims) 
(Fig.  86);  of  driving  in  pegs  of  ivory  (Figs. 
87  and  89),  nails,  staples  (Fig.  88);  or  of 
screwing  the  bones  together  with  iron  screws 
(Bockel);  and  of  fastening  the  fragments  with  small  metal  strips 
(aluminum,  Redard).     Recently  there  has  been  a  more  general  applica- 


Bone  suture.    (After  Hennequin 
and  Wille.) 


PSEUDART1I ni.'sis  OF  THE  JIl-MERUS. 


137 


tion  of  transplantation  methods,  particularly  those  of  J.  Wolff,  Midler, 
ami  Eiselsberg;  a  bone-periosteum  flap  attached  to  the  overlying  soft 


Fig.  86. 


Ivory  peg  inserted  in  the  medulla. 

Fig.  88. 


Guseenbaiier's  staple. 


I  k..  87. 


A  pseudarthrosis  nailed  together. 

Fig.  89. 


Fragments  rabbeted  and  fastened  with 
ivory  pegs. 


parts  is  cut  out  of  one  fragment,  shifted  in  the  long  axis  to  the  other,  and 
fastened  so  that  the  bone  unites  as  a  bridge  over  the  defect.    This 


138  INJURIES  OF  THE  UPPER  ARM. 

method  is  generally  a  minor  operation,  with  the  advantages  that  the 
fragments  do  not  have  to  be  fully  exposed  and  that  there  is  no  essen- 
tial shortening  of  the  extremity. 

Scheuer  recently  secured  union  of  a  severe  psendarthrosis  in  a  four- 
year-old  boy,  whose  arm  was  run  over,  in  a  very  original  manner:  after 
freshening  the  fracture-ends  he  implanted  a  tongue-shaped  flap  from  the 
thorax  containing  a  piece  of  the  fifth  rib.  The  rib  healed  in  by  bony 
union  ;  at  the  end  of  fourteen  days  the  skin  pedicle  was  divided. 
Bramann  produced  a  brilliant  result  in  a  severe  pseudarthrosis  of  the 
humerus  by  transplanting  a  piece  of  the  patient's  tibia  measuring 
2j  x  lj.Xj  inches. 


FRACTURES   OF  THE  HUMERUS  UNITING  WITH  DEFORMITY. 

In  spite  of  the  efficacy  of  present  methods  of  treatment  of  fractures 
of  the  arm,  cases  are  occasionally  seen  in  which  either  as  a  result  of  the 
indolence  of  the  patient  in  not  giving  attention  to  the  fracture  or  from 
insufficient  treatment  the  fracture  has  healed  with  more  or  less  deformity 
and  consequent  functional  loss.  Naturally  this  occurs  most  frequently  in 
compound  and  double  fractures,  etc.,  in  which  the  injuries  of  the  soft 
parts  prevent  accurate  application  of  the  splint.  In  young  children 
it  is  difficult  to  overcome  the  displacement  because  the  retention  splint 
rapidly  loses  its  hold  upon  the  parts  on  account  of  the  shortness  of 
the  lever-arm.  Most  of  the  pathological  museums  contain  specimens 
in  which  either  the  displaced  fragments  are  united  merely  by  a  lateral 
callus  or  the  angular  deformity  or  overriding  of  the  fragments  is.  con- 
siderable. Fractures  of  the  upper  part  of  the  arm  with  angular  union, 
the  upper  fragment  being  abducted,  the  lower  parallel  to  the  body,  cause 
functional  loss  in  limiting  the  elevation  of  the  arm. 

The  callus  remains  pliable  for  some  time,  so  that  the  deformity  may 
be  reduced  by  traction  and  countertraction  with  pressure  upon  the  pro- 
truding angle;  under  anaesthesia  it  can  be  corrected  in  one  sitting  and  is 
particularly  yielding  in  the  case  of  rhachitic  infraction  in  young  children 
that  so  frequently  heals  with  angular  deformity.  Bardenheuer  states  that 
it  is  often  possible  to  correct  old  angular  fractures  by  continuous  forcible 
extension.  Schreiber  states  that  the  same  can  be  accomplished  grad- 
ually with  Hessing's  sheath  apparatus  and  elastic  traction-bands.  If 
bony  union  is  already  established,  operation  is  almost  unavoidable,  and  is 
preferable  to  mechanical  osteoclasis.  Subcutaneous  or  open  osteotomy, 
linear  or  wedge-shaped,  are  the  typical  methods;  an  increasing  angular 
deformity  is  an  indication  preferably  for  open  osteotomy  with  excision  of  a 
wedge.  At  the  present  time  the  .r-ray  makes  it  possible  to  work  out  a  plan 
modified  for  each  case  in  that  the  skiagram  shows  where  to  divide  the 
bone,  or  whether  division  is  indicated  or  the  removal  of  a  projecting  frag- 
ment or  callus  is  sufficient.  The  treatment  after  osteotomy  is  the  same  as 
for  simple  fracture;  in  the  open  operation  one  should  not  neglect  to  secure 
the  advantage  of  solid  fixation  obtainable  by  means  of  the  suture  or  peg. 


WOl'M>*  OF  THE  UPPER  ARM. 


L39 


WOUNDS   OF  THE  UPPER  ARM. 

Gunshot  Injuries  of  the  Upper  Arm.  -Gunshot  injuries  of  the  arm 
are  among  the  most  frequent  injuries  in  war,  although  the  lower  extrem- 
ity is  affected  somewhat  more  often.  Shot-wounds  of  the  upper  arm 
are  sometimes  complicated  by  lesions  of  the  thorax  or  abdomen.  In  the 
Franco-Prussian  War,  among  32,307  wounds  of  the  upper  extremity 
there  were  :5041  of  the  upper  arm,  and  from  these  490  deaths.     Fischer 

I  cg.  90. 


Lines  of  fracture  in  typical  "  butterfly"  fracture  of  shaft  of  long  bones.     (Bornhaupt, ) 

gives  involvement  of  the  humerus  as  representing  13  per  cent,  of  the 
shot  injuries  of  the  upper  extremity  and  35  per  cent,  of  the  injuries  of 
the  upper  arm.  In  the  South  African  War  Matthiolius  gives  68  cases 
of  arm  involvement  in  343  instances  of  rifle- wound ;  among  these  there 
were  27  shot-wounds  of  the  soft  parts  and  41  of  the  bone;  among  25 
shot-wounds  of  the  shaft  in  the  upper  extremity  there  were  15  of  the 
humerus;  in  81  artillery  wounds  of  the  upper  extremity  there  were  9  of 
the  bones,  of  which  6  were  of  the  humerus. 


140  INJURIES  OF  THE  UPPER  ARM. 

Gunshot-wounds  of  the  shaft  as  produced  by  modern  firearms  almost 
always  cause  comminuted  fracture,  while  the  occurrence  of  contused  and 
furrow  shot-wounds  as  occasionally  produced  formerly  by  the  old  lead 
bullets  without  solution  of  continuity  is  doubtful  or  at  least  very  rare. 
Round-hole  shot-wounds,  the  usual  form  in  the  epiphysis,  are  excep- 
tional in  the  shaft,  and  are  then  fissured.  Transverse  and  oblique  frac- 
tures without  much  splintering  are,  as  a  rule,  the  results  of  tangential 
shots.  The  point-blank  shot-wound  of  the  modern  small-calibre  rifle 
produces  comminution  of  the  shaft  at  all  distance-  1000  to  1500  metres 
or  over),  and  usually  the  typical  form  of  "  butterfly-fracture."  (Fig.  00.) 
The  extent  of  the  zone  of  splintering  was  found  by  Kiittner  to  be 
approximately  the  same  at  all  distances  in  the  humerus  (9  to  10  cm.); 
on  the  other  hand,  the  size  and  number  of  splinters  varied  greatly. 
Large  and  small  splinters  are  produced  at  all  distances,  although  the 
large  splinters  are  most  numerous  at  long  range,  and  shattering  with 
numerous  small  splinters  more  frequent  at  short  range.  Accompanying 
thi-  comminution  there  are  severe  laceration  of  the  soft  parts  and  a 
large  wound  of  exit. 

In  gunshot-wounds  of  the  shaft  the  projectile  or  a  portion  of  the  same 
frequently  becomes  lodged.  Wounds  of  the  soft  parts  vary  from  simple 
grazed  or  furrow  wounds  to  the  severest  grades  of  laceration  produced 
by  "key-holers"  and  short-range  and  artillery  shots.  In  the  foregoing, 
the  author  has  followed  chiefly  the  reports  of  Kiittner  and  Matthiolius, 
which  are  particularly  valuable,  as  they  represent  the  result  of  practical 
experience  in  recent  wars.  The  numerous  and  extensive  shot  experi- 
ments made  by  Bruns,  Kocher,  Coler,  Schjerning,  Habart,  Bircher  and 
others,  upon  which  is  built  up  the  scientific  knowledge  of  the  action 
of  modern  firearms,  are  beyond  the  compass  of  available  space. 

<iunshot  injuries  of  the  vessels  and  nerves  are  responsible  for  the 
greater  percentage  of  those  cases  later  invalidated  as  the  result  of  shot- 
wounds.  In  the  Franco-Prussian  War  the  axillary  artery  had  to  be 
ligated  in  14  cases,  the  brachial  in  25. 

Diagnosis. — The  diagnosis  of  gunshot-fracture  of  the  humerus  is  not 
more  difficult  than  that  of  any  other  fracture  of  the  shaft.  On  the  other 
hand,  it  is  difficult  to  determine  the  extent  of  the  splintering,  particularly 
if  the  splinter  is  only  -lightly  displaced  and  held  by  the  periosteum. 
Sometimes  the  bone  is  sensitive  to  pressure  at  some  distance  from  the 
apparent  fracture,  a  sign  more  referable  to  fissures  than  to  splinters. 
Kiittner  has  frequently  indicated  the  value  of  the  x-ray  in  >hot-fractures. 

Pure  transverse  and  oblique  fractures  heal  usually  in  from  three  to 
five  weeks;  with  marked  splintering  consolidation  is  often  delayed. 
There  may  still  be  false  motion  after  six  weeks.  Actual  pseudarthrosis 
is  apparently  rare.  Severe  destruction  of  the  soft  parts  may  not  only 
prevent  primary  union,  but  also  compromise  the  final  result  by  producing 
cicatricial  contractures,  adhesion  of  the  cicatrix  to  the  bone,  and  pro- 
tracted sensitiveness. 

Treatment. — The  value  of  modern  methods  is  best  shown  in  the  med- 
ical report  of  Matthiolius,  who  gives  only  1  case  of  death  among  09 


WOUNDS  OF  THE  UPPER  ARM.  141 

injuries  of  the  arm  68  small-arm,  i!l  artillery  wounds-  and  in  this 
case,  seen  on  the  sixteenth  day,  there  was  well-cleveloped  sepsis  beyond 
the  ;ii<l  of  amputation.  Except  in  this  one  case  amputation  of  the  arm 
was  never  necessary.  In  contrast  to  these  recent  results  there  is  no 
advantage  in  discussing  the  statistics  of  previous  wars  with  their  average 
mortality  of  20  per  cent,  for  shot-fractures  of  the  humerus  and  30  to  -40 
per  cent,  for  amputation.  Fortunately  interest  in  these  figures  to-day 
is  purely  historical. 

The  treatment  for  the  cases  in  which  the  skin-wound  is  small  can  be 
dismissed  in  a  few  words,  namely,  aseptic  occlusion  and  treatment  of 
the  fracture  as  if  it  were  subcutaneous.  Even  the  large  wounds  of  exit 
should  be  treated  conservatively;  primary  operation  will  be  considered 
only  to  check  hemorrhage  or  remove  superficially  situated  splinters. 
The  occurrence  of  infection  will  naturally  demand  thorough  cleansing, 
careful  removal  of  loose  splinters,  and  free  drainage. 

Severe  Lacerated  Wounds  Machine  Accidents  I  and  Evulsion  of 
the  Upper  Arm. — Severe  injuries  of  the  tipper  arm  as  produced  by 
machinery  accidents,  run-over  accidents,  crushing,  by  falling  bodies, 
explosions,  etc.,  may  involve  not  only  individual  tissues,  but  also  larger 
or  smaller  areas  of  the  soft  parts  and  bones  of  the  arm.  The  first 
question  is  naturally  whether  there  is  a  prospect  of  preserving  the  arm 
or  whether  primary  amputation  is  indicated.  Injury  of  the  large  vessels 
alone,  of  the  muscles  and  nerves — if  they  are  not  too  much  torn — or 
extensive  comminuted  fractures,  even  with  great  loss  of  bone-substance, 
are  not  an  indication  per  sc  for  amputation,  especially  if  the  hand  and 
forearm  are  intact,  as  the  nerves  can  be  sutured  and  the  blood-supply 
restored  through  the  collateral  circulation.  Very  often  a  certain  amount 
of  time  is  necessary  in  order  to  come  to  a  decision;  also  in  such  cases 
one  must  await  the  termination  of  the  resulting  shock.  In  doubtful  cases 
primary  interference  should  be  limited  to  absolutely  necessary  details, 
namely,  removal  of  pointed  fragments,  loose  splinters,  torn  and  soiled 
portions  of  skin  and  muscle,  and  ligation  of  torn  arteries.  If  there  are 
signs  of  beginning  gangrene  or  infection,  amputation  should  be  con- 
sidered. Great  stress  has  been  laid  recently  upon  systematic  conserva- 
tism in  injuries  of  the  extremities,  chiefly  by  Reclus  and  the  French 
authors.  The  shock  accompanying  amputation  for  severe  injuries  of 
the  extremities  should  be  avoided  by  delaying  amputation,  and  the  limb 
dressed  as  follows:  After  the  skin  has  been  washed  with  antiseptics  and 
cleaned  with  turpentine  or  ether,  the  edges  of  the  wound  are  well  separated 
and  all  cavities  washed  out  with  sterile  water,  clots,  foreign  bodies,  and 
loose  splinters  removed,  the  surfaces  disinfected  with  a  strong  antiseptic 
solution,  gauze  strips  laid  in  all  the  recesses  and  cavities  of  the  wound, 
the  former  being  soaked  in  a  "polvantiseptic  pomade;"  the  soft  parts 
are  then  wrapped  in  antiseptic  gauze  and  the  dressing  changed  infre- 
quently. According  to  Reclus,  the  results  are  excellent  and  large 
portions  of  the  limb  often  preserved  which  at  first  appeared  hopeless. 

In  industrial  centres  one  frequently  sees  severe  "combined  injuries" 
of  the  upper  extremity,  namely,  of  the  hand,  forearm,  and  upper  arm, 


142  INJURIES  OF  THE  UPPER  ARM. 

as  in  accidents  caused  by  rotary  machinery,  where  the  hand,  forearm, 
and  upper  arm  are  crushed  in  turn.  Schreiber  saw  numerous  cases  of 
recovery  with  a  useful  limb  in  which  the  hand  had  been  partly  mangled, 
the  bones  of  the  forearm  broken  in  several  places,  the  upper  arm 
compound  fractured  or  dislocated,  and  the  soft  parts  severely  dam- 
aged, often  with  merely  an  inner  bridge  of  tissue  remaining.  In  such 
cases  of  combined  machinery  injuries  amputation,  if  necessary,  should 
not  always  be  made  at  the  point  of  injury,  for  even  the  parts  involved 
in  a  compound  fracture  may  be  preserved  and  a  correspondingly  better 
prothesis  applied.  Such  severe  injuries  of  the  arm  may  sometimes 
extend  to  the  shoulder  and  the  shock  and  loss  of  blood  menace  life. 
Autotransfusion  or  saline  infusion  and  stimulants  are  of  life-saving 
importance. 

Avulsion  and  evulsion  of  the  arm  may  be  caused  by  machinery  belting, 
bombshell  or  mine  explosions,  etc.  Adelmann  collected  14  cases  of  evul- 
sion of  the  arm  and  scapula,  Rogers  1 1,  and  Berger  6,  and  since  then 
several  others  have  been  added.  The  patients  affected  were  generally 
young  and  in  many  recovery  was  rapid  and  unexpected.  The  trunk  of 
the  artery  is  greatly  stretched  by  the  violence;  the  intima  curls  up  so  that 
the  hemorrhage  is  often  surprisingly  slight.  Recovery  has  been  observed 
occasionally  even  when  there  was  extensive  laceration  of  the  soft  parts 
of  the  chest  and  back. 

Although  the  bleeding  is  often  slight,  the  stump  of  the  artery  should  be 
ligated  at  once  and  the  projecting  ends  of  the  nerves  pulled  out  and  cut 
off.  As  a  rule  the  skin  should  not  be  sutured  primarily  even  if  there 
are  well-adapted  skin-flaps,  but  should  be  simply  held  by  a  few  reten- 
tion sutures.  If  a  part  of  the  clavicle  projects,  the  bone  should  be 
resected,  as  it  may  be  drawn  up  later  by  the  sternomastoid  and  cause 
trouble.  Large  defective  skin  areas  may  require  extensive  skin- 
grafting.  The  arm  is  sometimes  torn  off  lower  down.  The  cases  are 
particularly  unfavorable  in  which  the  wound  is  greatly  lacerated  and 
soiled,  as  in  boiler  explosions;  even  more  dreaded  are  the  cases  of 
avulsion  of  the  arm  caused  by  beasts  of  prey,  in  which  the  muscles  are 
torn  by  the  teeth  as  by  a  comb  and  infected  by  the  septic  germs  on  the 
teeth. 


CHAPTER  VI. 

DISEASES  OF  THE  UPPER  ARM. 
DISEASES  OF  THE  SOFT  PARTS  OF  THE  UPPER  ARM. 

Various  inflammations  are  observed  in  the  skin  of  the  upper  arm: 
erysipelas  is  more  common  on  the  hand  and  forearm,  but  may  be  trans- 
mitted also  from  the  head;  lymphangitis  and  superficial  phlegmon  may 
spread  from  the  peripheral  part  of  the  extremity,  from  the  olecranon 
bursa,  or  from  inflammation  of  the  glands  in  the  bicipital  groove.  These 
processes,  usually  starting  from  small  undetected  wounds,  may  produce 
cellulitis  and  sloughing  of  the  subcutaneous  tissue  or  gangrene  of  the 
skin.  The  resulting  large  granulating  areas  require  skin-grafting  to 
prevent  contracture.  Jaboulay  distinguishes,  besides  the  usual  subcu- 
taneous phlegmon  of  the  arm,  one  coursing  within  the  sheath  of  the 
vessels  beneath  the  fascia,  and  characterized  by  a  cord-like  thickening 
running  along  the  inner  side  of  the  arm  to  the  axilla,  which  is  painful 
on  abducting  the  arm.  In  this  form  the  fascia  shoidd  be  incised  even 
if  it  does  not  appear  discolored  and  the  focus  of  inflammation  exposed. 

More  serious  than  the  common  cellulitis  of  the  arm  is  the  septic  infec- 
tion characterized  by  superficial  and  deep  infiltration,  rapid  diffusion, 
rapid  severe  swelling,  and  discoloration  of  the  skin,  with  crackling  and 
vesicles.  It  is  usually  accompanied  by  severe  constitutional  disturbance. 
This  affection,  which  Pirogoff  calls  acute  purulent  oedema,  known  also 
as  emphysematous  gangrene,  the  gangrene  foudroyante  of  Maissoneuve, 
the  panphlegmone  gangrenosa  of  Fischer,  and  regarded  by  many  as 
identical  with  the  sympathetic  anthrax  ("Rauschbrand")  of  animals, 
has  an  extremely  virulent  course.  In  most  of  the  cases  it  is  caused  by 
the  bacillus  of  malignant  oedema,  or  there  is  a  mixed  infection  of  the 
former  with  streptococcus;  it  is  usually  transmitted  from  the  hand  and 
forearm.  It  may  occur  primarily  in  the  upper  arm  from  improper  treat- 
ment of  injuries,  especially  shot-wounds,  bites,  etc.  If  there  is  still 
hope  that  there  is  no  general  sepsis,  the  arm  is  amputated.  Emphyse- 
matous crackling  extending  beyond  the  arm  is  not  a  counterindication 
per  se  against  amputation.  The  skin-flaps  are  not  sutured  till  later, 
after  the  wound  has  become  clean.  Phlegmon  with  a  more  insidious 
onset  is  occasionally  seen  on  the  inner  side  of  the  upper  arm,  arising 
from  inflammation  of  the  lymphatics  and  glands  in  the  bicipital  groove; 
when  following  diseases  of  the  olecranon  bursa,  it  may  be  more  on  the 
posterior  surface. 

Since  Sigmund's  observation  of  the  swelling  of  the  cubital  glands  in 
syphilis  the  symptom  has  gained  great  importance  as  being  character- 

(143) 


144  DISEASES  OF  THE  UPPER  ARM. 

istic  of  lues.  It  would  be  a  great  mistake  to  regard  all  hard  or  swollen 
cubital  glands  as  specific;  mild  peripheral  infections  often  produce  such 
an  adenitis,  or  the  glands  may  be  tuberculous  and  result  from  lupus, 
tuberculosis  verrucosa,  or  fungous  processes  on  the  hand  and  forearm. 
Sometimes  an  entire  chain  of  such  swollen  glands  extends  from  the 
internal  epicondyle  to  the  axilla  and  goes  on  to  the  formation  of  abscesses 
with  caseous  softening  and  protracted  suppuration  and  fistulas. 

Disease  of  the  bursa?  of  the  upper  arm  is  not  common,  but  in  conse- 
quence of  such  the  region  of  the  triceps  may  be  involved,  particularly 
following  the  frequent  inflammation  of  the  olecranon  bursa.  A  bursa 
may  form  upon  abnormal  bony  prominences — exostoses,  callus — and 
cause  inflammatory  irritation  or  the  production  of  a  hygroma.  Fano 
saw  a  slater  with  an  accidental  bursa  at  the  insertion  of  the  deltoid. 

The  skin  of  the  upper  arm  may  be  the  seat  of  lupus  or  other  ulcers; 
of  various  neoplasms,  such  as  cornu  cutaneum  (Denuce) ;  of  mollus- 
cum,  nsevus,  telangiectasis,  cavernoma,  lymphangioma,  lipoma,  sar- 
coma, and  carcinoma,  the  latter  particularly  starting  from  cicatrices 
(Waldeyer),  and  lupous  ulcers  (Kaposi). 


DISEASES  OF  THE  MUSCLES  OF  THE  UPPER  ARM. 

Abscess. — The  muscles  may  be  the  seat  of  primary  acute  inflamma- 
tion leading  to  suppuration;  in  two  instances  Schreiber  saw  an  acute 
abscess  in  the  biceps  developing  rapidly  and  without  apparent  cause. 
Recovery  followed  promptly  after  incision  through  the  intact  overlying 
part  of  the  muscle.  Cold  abscesses  in  the  arm  muscles  are  a  rather 
frequent  observation,  and  are  to  be  regarded  as  tuberculous;  in  a  few 
cases  of  Schreiber's  there  was  a  hard  swelling  in  the  muscle,  so  the 
affection  is  easily  mistaken  for  a  solid  tumor.  The  wall  of  the  slowly 
developing  abscess  is  usually  thick  and  somewhat  lobulated. 

Gumma  and  diffuse  syphilitic  myositis  sometimes  occur  in  the 
muscles  of  the  arm,  especially  in  the  biceps  and  triceps,  the  muscle  being 
hard  and  thickened  throughout;  also  echinococcus,  occasionally  large- 
sized — a  man's  head — and  pushing  the  tissues  before  it.  These  affec- 
tions are  frequently  mistaken,  often  for  neoplasms.  Dupuytren,  Demar- 
quay,  Soulie  and  others  saw  hydatid  cysts  in  the  biceps,  Gerdy  saw  the 
same  in  the  brachialis,  and  Nelaton  described  a  large  echinococcus  cyst 
of  the  belly  of  the  triceps. 

Ossification  occurs  in  the  muscles  of  the  arm,  either  as  a  local  mani- 
festation of  myositis  ossificans,  or  more  frequently  from  occupational 
injury,  such  as  the  so-called  "exercise-bone"  of  soldiers,  or  following 
a  single  local  injury.  The  brachialis  seems  particularly  disposed  to 
ossification.  In  the  author's  experience  and  that  of  others  the  ossification 
following  a  single  injury  usually  seems  to  be  referable  to  a  lesion  of  the 
underlying  periosteum,  either  direct  avulsion  or  displacement. 

Cavernous  angioma  is  rare;  it  is  often  difficult  to  excise,  as  it  branches 
widelv  and  mav  be  scattered  diffusely  through  the  muscles;  it  occurs 


DISEASES  OF  THE  NERVES  OF  THE  UPPER  ARM.  145 

more  often  in  the  forearm  than  in  the  tipper  arm.  It  is  recognizable  by 
its  slow  growth,  compressibility,  diminution  under  pressure  of  an  clastic 

bandage,  and  by  the  Mood  obtained  by  puncture.  Bayha  excised  an 
angioma  from  the  triceps.  Heinlein  removed  a  subfascial  intermuscular 
cavernous  angioma,  goose-egg  size,  from  the  outer  side  of  the  upper  arm. 
Intramuscular  lipoma  is  rare.  Schreiber  saw  an  intramuscular  lipoma 
in  the  biceps  of  a  young  woman  that  was  very  difficult  to  diagnosticate; 
the  ovoid  swelling  in  the  muscle  had  developed  rapidly  to  the  size  of 
two  fists;  no  lobulation  could  be  felt  through  the  tense  muscle,  so  that 
sarcoma  was  suspected.  An  analogous  case  was  operated  upon  in  Bruns' 
clinic  by  Hofmeister.  Malignant  tumors,  especially  sarcoma,  also  occur 
in  the  muscles  of  the  upper  arm. 


DISEASES  OF  THE  VESSELS   OF  THE  UPPER  ARM. 

Aneurism  may  follow  injury  of  the  brachial  artery  or  less  frequently 
occur  spontaneously.  In  551  spontaneous  aneurisms  Crisp  found  only 
1  of  the  brachial  artery.  The  attempt  should  first  be  made  to  effect 
a  cure  by  methodical  digital  compression.  Sarazin  devised  a  simple 
apparatus  for  producing  alternating  elastic  compression;  it  consists  of 
a  retention-splint  with  two  fenestra  over  the  artery;  pressure  is  made 
alternately  in  the  fenestra  by  means  of  a  cork  pad  held  by  elastic  bands, 
the  splint  meanwhile  preventing  constriction.  If  compression  is  not 
successful,  or  if  in  spite  of  it  increase  is  observed,  the  artery  should  be 
ligated  above  and  below  and  the  aneurism  excised.  Even  in  the  latter 
case  previous  compression  is  valuable  in  furthering  development  of 
the  collateral  circulation. 

Krause  and  Nicoladoni  report  single  instances  of  cirsoid  aneurisms 
and  diffuse  phlebarteriectasia  of  congenital  origin;  they  arise,  as  far 
as  is  known,  in  the  hand  and  forearm  and  extend  upward.  Thus  far 
amputation  has  been  the  only  successful  treatment,  and  is  delayed 
naturally  until  demanded  by  subjective  discomfort  or  beginning  ulcer- 
ation. 


DISEASES  OF  THE  NERVES   OF  THE  UPPER  ARM. 

Neuritis  interests  the  surgeon  chiefly  in  that  it  frequently  follows 
trauma;  as  ascending  neuritis  it  may  cause  severe  neuralgia,  functional 
disturbance,  and  later  trophic  changes,  particularly  in  the  hand.  Except 
in  the  milder  cases,  brachial  neuritis  is  a  chronic  disease  often  lasting 
a  year  or  longer.  In  all  cases  in  which  the  pain  is  severe  there  is  danger 
of  stiffening,  as  the  patients  carefully  avoid  motion ;  this  must  be  com- 
bated by  massage  and  judicious  exercises.  The  special  neurological 
treatment  cannot  be  discussed  here. 

Neuroma  is  a  relatively  frequent  affection  of  the  nerves  of  the  arm, 
especially  the  median  and  musculospiral,  although  it  also  occurs  in  the 
Vol.  III.— 10 


146  DISEASES  OF  THE  UPPER  ARM. 

musculocutaneous  and  internal  cutaneous.  The  tumors  are  usually  small, 
flaxseed  to  hazelnut  size,  although  larger  have  been  seen.  They  are  gen- 
erally ovoid  or  spindle-shaped,  start  in  the  neurilemma  and  bulge  more  at 
the  side  of  the  trunk  or  grow  outward  from  within  the  nerve,  pushing 
the  fibres  apart  and  forming  a  cylindrical  swelling — trunk  neuroma. 
The  majority  of  neuromata  in  the  arm  are  fibromata  of  the  nerve- 
sheath,  rarely  true  neuromata,  v.  Brims  describes  a  peculiar  plexiform 
fibroneuroma,  or  scirrhous  neuroma,  in  which  there  is  a  new  growth  of 
nerve-fibres,  endothelial  cells,  and  connective  tissue,  producing  a  diffuse 
nodular  hypertrophy  of  entire  nerves.  In  135  neuromata  of  the  large 
trunks  of  the  extremities  Courvoisier  found  those  of  the  upper  extremity 
involved  in  63  per  cent.,  and  among  those  the  median  in  30  per  cent., 
the  ulnar  in  15  per  cent.,  and  the  musculospiral  in  10  per  cent,  of  the 
cases.  In  the  upper  arm  there  were  8  of  the  median,  10  of  the  ulnar, 
and  8  of  the  musculospiral.  The  so-called  tubercula  dolorosa  is  also 
to  be  classified  here;  small,  subcutaneous,  very  painful  nodules,  fre- 
quently multiple  and  rarely  of  any  size;  they  are  seldom  seen  on  the 
upper  extremity. 

Diagnosis. — The  diagnosis  is  usually  not  difficult,  as  the  nerves  can 
be  easily  felt,  and  are  often  very  sensitive  to  pressure,  pain  being  severe 
and  spontaneous.  The  neuroma  may  be  accompanied  by  paresthesias, 
exceptionally  by  motor  disturbances,  or  they  may  cause  epileptic 
attacks.  The  closer  the  relation  of  the  tumor  to  the  nerve,  the  more 
severe  and  manifold  are  the  symptoms.  The  worst  cases  are  those 
in  which  the  entire  nerve  is  involved  in  the  growth.  The  so-called 
multiple  neuroma  often  gives  surprisingly  few  symptoms.  In  several 
of  the  anatomical  museums  there  are  large  neuromata  of  the  plexus 
which  gave  hardly  any  symptoms  during  life. 

Prognosis. — The  prognosis  is  always  doubtful,  especially  in  the  case 
of  neuromata  of  rapid  growth,  which  are  probably  malignant. 

Treatment. — As  soon  as  the  tumors  produce  any  considerable  dis- 
turbance, the  only  treatment  is  extirpation;  this  is  simple  if  the  neuroma 
is  parietal  and  easily  separated  from  the  trunk,  or  if  it  has  merely 
pushed  the  nerve-fibres  apart,  in  which  case  it  can  be  peeled  out  through 
a  longitudinal  incision  and  the  nerve  function  often  fully  preserved. 
The  operation  is  more  difficult  if  the  growth  is  less  defined  and  more 
rapid;  in  this  case,  as  in  an  instance  reported  by  Kraussold,  it  is  neces- 
sary to  resect  the  nerve  and  suture,  so  that  the  surgeon  will  be  obliged 
in  many  instances  to  do  a  plastic  operation  to  bridge  over  the  defect. 
It  often  happens  after  excising  a  neuroma  that  the  symptoms  of  loss  of 
function  are  slight  or  absent,  so  that  a  sort  of  collateral  nerve  conduc- 
tion gradually  established  during  the  process  of  disease  and  destruction 
of  the  nerve  must  be  assumed.  Monod  reports  a  neuroma  of  the  mus- 
culospiral which  he  excised  with  a  piece  of  the  nerve  H  inches  long, 
2f  inches  above  the  epicondyle;  he  then  sutured  the  nerve-ends;  there 
was  no  paralysis,  only  slight  numbness. 

Malignant  neuromata,  which  are  chiefly  sarcomatous  or  myxo- 
matous, are  more  frequent  than  one  would  conclude  from  the  literature. 


DISK.  1  s /..s  OF  THE  II UMER  US.  1 47 

Volkmann  called  attention  to  the  malignant  nature  of  neuroma  and  its 
tendency  to  rupture,  ulceration,  and  slow  advance  centripetally  beneath 
the  neurilemma,  and  to  metastasis.  The  growth  is  often  seen  either 
as  single  tumors  growing  rapidly  to  the  size  of  an  egg  or  "apple,  or  as 
multiple  swellings  in  the  trunk,  like  a  rosary,  or  bulbous.  They  are 
met  with  most  frequently  in  the  median.  As  to  the  mode  of  origin 
of  malignant  neuroma,  (Jarre  distinguishes  between  primary  sarcoma 
and  secondary  malignant  neuroma  (recurrent  neuroma  of  Virchow, 
regarded  as  malignant  transformation  of  congenital  multiple  neuro- 
fibroma; the  congenital  elephantiasis  neuromatodes  of  v.  Brims). 

Symptoms. — The  nervous  disturbances  are  often  slight,  although 
there  mav  be  pain  and  abnormal  sensations  at  the  outset.  If  the  tumor 
is  more  advanced,  there  are  pain,  tingling,  itching,  diminished  sensi- 
bility in  the  area  supplied,  weakness  or  paralysis,  and  trophic  changes 
in  the  entire  extremity — profuse  sweating  or  subnormal  temperature. 
Pressure  on  the  tumor  is  painful.  The  consistence  varies.  In  thin 
subjects  the  nerve-trunk  can  be  felt  entering  the  tumor.  If  the  growth 
has  not  involved  the  adjacent  soft  parts  it  is  movable,  but  is  usually 
immovable  if  it  has  spread,  is  adherent  to  the  skin,  or  has  disintegrated. 
Malignant  neuroma  rarely  produces  metastasis  in  the  lymph-glands  or 
elsewhere.  If  the  malignant  neuroma  is  secondary,  careful  examina- 
tion of  the  patient  usually  gives  evidence  for  assuming  a  congenital 
elephantiasis  neuromatodes. 

Prognosis. — The  prognosis  is  unfavorable.  The  soft  sarcoma  is  the 
most  malignant,  although  the  more  fibroid  neuroma  may  have  a  malig- 
nant course,  spread  rapidly,  and  recur,  after  operative  removal,  beyond 
the  area  of  operation. 

Treatment. — Removal  is  indicated  if  the  tumor  is  still  encapsulated 
and  not  adherent  to  the  adjacent  structures.  Krause  condemns  the 
policy  of  shelling  out  a  tumor  situated  in  the  middle  of  the  nerve,  and 
advocates  resection  of  the  nerve  with  the  tumor.  The  decision  as  to 
the  mode  of  operation  is  dependent,  in  the  case  of  circumscribed  tumors, 
chiefly  upon  the  rapidity  of  growth,  as  the  latter  is  the  best  evidence 
of  the  degree  of  malignancy.  If  the  tumor  has  already  spread  diffusely 
in  the  soft  parts,  or  if  there  is  a  recurrence,  amputation  or  exartieula- 
tion  of  the  arm  or  of  the  entire  shoulder  is  indicated.  Naturally  the 
level  of  the  amputation  will  be  decided  after  the  nerve  has  been  exposed 
and  its  condition  ascertained.  Courvoisier  reports  extirpation  and 
resection  of  the  median  in  19  cases,  of  the  ulnar  in  11,  of  the  musculo- 
spiral  in  7.  In  one  instance  of  malignant  neuroma  of  the  median,  in 
which  the  sheath  of  the  brachial  artery  was  adherent  for  some  distance, 
the  resection  was  combined  with  double  ligation  of  the  artery. 


DISEASES   OF  THE  HUMERUS. 

Acute  Osteomyelitis  of  the  Humerus, — The  osteomyelitis  produced 
by  Staphylococcus  pyogenes  aureus  is  not  infrequently  localized  in  the 


148 


DISEASES  OF  THE  UPPER  ARM. 


Fig.  91. 


humerus,  although  less  common  here  than  in  the  femur  and  tibia.  In  470 
cases  of  acute  osteomyelitis  of  the  long  bones  reported  by  Haaga  from 
Brims'  clinic  there  were  52  of  the  humerus — 11  per  cent. ;  among  these,  28 
of  the  upper  end,  16  of  the  middle,  11  of  the  lower  end.  The  general 
clinical  picture  of  osteomyelitis  will  be  found  in  the  description  of  the 
disease  in  the  femur.  If  the  focus  is  situated  near  the  epiphyseal  line 
or  spreads  toward  it,  there  is  often  suppuration  and  separation  of  the 
epiphysis  (Fig.  91);  the  process  does  not  advance  farther,  however,  but 
perforates  outward,  and  the  end  of  the  shaft, 
loosened  by  the  suppuration,  is  displaced  by 
the  weight  and  movements  of  the  limb.  This 
happens  particularly  in  the  upper  end  of  the 
humerus,  and  sometimes  produces  deformity 
similar  to  that  of  fracture  of  the  epiphysis. 
The  pus  usually  perforates  on  the  anterior  sur- 
face; as  the  epiphyseal  line  is  entirely  extra- 
articular, there  is  no  suppuration  in  the  shoulder- 
joint  in  contrast  to  the  condition  of  the  hip-joint 
in  osteomyelitis  of  the  femur.  Suppuration  at 
the  epiphysis  is  often  followed  by  considerable 
retardation  in  growth,  as  shown  in  Fig.  92. 
Shortening  of  even  2  to  4  inches  has  been  seen. 
Treatment. — The  diagnosis  being  established, 
the  diseased  spot  is  exposed;  on  the  upper  end 
of  the  humerus  this  is  done  best  through  an 
incision  along  the  anterior  border  of  the  deltoid. 
If  oily  pus  is  discharged,  indicating  a  focus  in 
the  bone  near  the  epiphysis,  the  shaft  is  tre- 
phined. Exceptionally  there  is  a  so-called  bipolar  ostitis,  namely,  at  both 
ends  of  the  shaft.  In  extensive  osteomyelitis  of  the  shaft  there  is  more 
or  less  general  necrosis,  sequestra  being  scattered  irregularly  through  the 
bone;  or  there  may  be  total  necrosis  of  the  shaft,  chiefly  in  children, 
the  entire  shaft  between  the  epiphyses  being  necrotic.  The  fistulas 
open  mostly  on  the  outer  side  of  the  arm. 

Separation  of  the  sequestrum  is  usually  complete  in  from  two  to 
three  months;  if  this  is  verified  by  the  sound,  it  is  removed.  It  is  most 
accessible  through  an  incision  along  the  external  bicipital  groove;  the 
musculospiral  nerve  is  protected,  the  periosteum  exposed  and  lifted 
from  the  bone,  and  the  latter  then  chiselled  away,  beginning  at  the 
fistula,  until  the  sequestrum  can  be  easily  removed  and  the  cavity 
cleaned.  The  defective  area  of  bone  may  be  filled  in  by  a  plastic  oper- 
ation. Bardenheuer  covered  in  the  upper  half  of  the  humerus  by 
transplanting  the  spine  of  the  scapula  with  the  acromion  attached  and 
suturing  it  to  the  new  bone  formed  on  the  lower  end  of  the  humerus. 
There  was  subsequently  good  abduction  of  the  arm. 

Exceptionally,  chronic  osteomyelitis  of  the  humerus  is  seen,  gradually 
producing  considerable  hyperostosis;  it  is  accompanied  by  severe  pain, 
but  often  by  very  slight  symptoms  of  inflammation.     Oilier  explained 


Separation  of  the  epiphysis 
and  necrosis  of  the  shaft.  (Es- 
march.) 


DISEASES  (JE  THE  HIM  Kill's. 


149 


the  neuralgic  pains  <>t*  this  form  by  a  sort  of  neuritis  of  the  nerves  of 
the  medulla,  the  nerves  being  compressed  in  the  unyielding  meshes 
of  the  hone.  He  states  that  it  was  often  necessary  to  trephine  the 
humerus  to  remove  the  foci  of  chronic  inflammation,  namely,  the 
remains  of  an  acute  inflam- 
mation. In  such  cases,  to  pre-  Fig.  92. 
vent  recurrence  of  the  pain, 
the  medulla  should  be  opened 
freely  and  cleaned  out. 

Tuberculosis  of  the  Shaft 
of  the  Humerus. — Whereas 
tuberculous  foci  in  the  ends  of 
the  shaft,  in  the  epiphysis,  and, 
in  very  extensive  disease  of  the 
head  of  the  humerus,  a  diffuse 
infiltration  into  the  medullary 
cavity,  are  of  frequent  occur- 
rence, isolated  primary  tuber- 
culosis of  the  shaft,  either  in 
the  form  of  small  periosteal 
foci  or  primary  tuberculous 
osteomyelitis,  is  rare.  The 
diagnosis  is  aided  by  the  his- 
tory, the  poor  general  condi- 
tion, and  the  crumbling  case- 
ous character  of  the  pus,  but 
is  positive  only  by  demonstra- 
ting the  presence  of  tubercle 
bacilli  and  nodules. 

Syphilitic  Affections  of  the 
Humerus.  —  Syphilitic  osteo- 
chondritis sometimes  accom- 
panies syphilis  in  the  newborn  and  may  cause  loosening  and  separation 
of  the  epiphysis.  Its  interest  is  chiefly  pathologico-anatomical  and 
medico-legal.  Gummatous  ostitis  is  not  infrequent  in  the  humerus  in 
acquired  as  well  as  congenital  lues,  and  is  usually  combined  with  lesions 
elsewhere.  If  a  sequestrum  results,  surgical  interference  is  necessary. 
Syphilis  of  the  humerus  is  important  surgically  chiefly  on  account  of 
the  spontaneous  fracture  sometimes  resulting  from  gummatous  absorp- 
tion of  the  bone.  The  author  has  seen  such  spontaneous  fractures 
many  times.  Union  usually  follows  the  exhibition  of  potassium  iodide, 
but  pseudarthrosis  may  supervene,  as  noted  by  Stromeyer,  in  spite  of 
specific  treatment. 

Tumors  of  the  Humerus. — Tumors  are  not  unusual  in  the  humerus, 
and  are  more  frequently  situated  in  the  upper  part  near  the  epiphysis, 
less  so  in  the  middle  and  lowrer  thirds.  We  distinguish:  benign  forms 
— exostoses,  chondroma,  and  cysts;  malignant  forms — sarcoma,  cysto- 
sarcoma,  myxosarcoma,  and  carcinoma. 


\ 

Arrested  growth  due  to  osteomyelitis  of  the  upper 
end  of  the  humerus.     (Schreiber.) 


250  DISEASES  OF  THE  UPPER  ABM. 

Enchondroma. — Enchondroma  is  sometimes  a  local  manifestation 
of  multiple  chondromata  of  the  skeleton  and  is  usually  situated  at  the 
upper  end;  it  is  more  common  in  youth.  It  is  generally  benign,  its 
growth  ceasing  as  a  rule  with  that  of  the  bone.  Solitary  chondroma  and 
osteoid  chondroma  of  the  humerus  are  sometimes  very  large,  and  in 
the  course  of  years  may  grow  to  enormous  size,  as  in  a  case  of  Atkinson's, 
in  which  the  limb  at  the  end  of  twelve  years  was  1  metre  in  circum- 
ference and  weighed  36T3^  pounds  as  the  effect  of  the  tumor.  Myxo- 
chondromata  of  the  humerus  undergoing  softening  and  mucoid  degen- 
eration are  to  be  classified  usually  among  malignant  tumors. 

Exostosis. — Exostosis  is  rather  frequent,  especially  at  the  upper  end, 
and  may  be  solitary  or  multiple,  particularly  at  the  epiphysis,  and  form 

Fig.  93. 


Cartilaginous  exostosis  of  the  upper  end  of  the  humerus,     (v.  Brims.) 

knobbed,  bulbous,  gibbous,  or  uncinate  bony  excrescences.  There  may 
be  typical  supracondyloid  exostosis  on  the  lower  end.  The  cartilaginous 
exostosis  (Fig.  93),  covered  with  a  layer  of  cartilage,  and  thus  identified 
as  a  formation  resulting  from  disturbances  in  the  growth  of  the  inter- 
mediary cartilage,  occurs  on  the  humerus  as  an  excrescence  varying 
from  the  size  of  a  hazelnut  to  that  of  a  fist.  In  regard  to  the  origin 
of  the  multiple  cartilaginous  exostoses  apt  to  appear  about  the  anus 
in  childhood,  there  is  proof  of  heredity  through  several  generations. 

Symptoms. — The  symptoms  of  exostosis  are  the  gradual  growth  of 
a  hard  bulbous  or  gibbous  tumor,  generally  easily  felt,  and  occasionally 


DISEA  SES  OF  THE  II UMER  US.  151 

considerable  functional  disturbance,  especially  limitation  of  abduction 
and  rotation  of  the  arm.  Pressure  of  the  exostosis  upon  the  nerve  may 
produce  considerable  discomfort.  Stanley  saw  an  exostosis  at  the 
lower  inner  part  of  the  arm  which  produced  severe  pain  in  the  region 
supplied  by  the  ulnar,  and  another  which  had  pierced  directly  through 
the  ulnar  and  split  it  into  halves. 

PROGNOSIS. — Important  for  the  prognosis  is  the  circumstance  that 
in  childhood  the  growth  of  the  exostosis  ceases  with  that  of  the  bone. 
The  axial  growth  of  the  upper  arm  always  suffers  if  the  exostosis  is 
large,  so  that  the  arm  may  be  much  shorter  than  its  mate. 

Treatment. — As  soon  as  an  exostosis  occasions  much  disturbance 
it  should  be  chiselled  off,  a  simple  procedure  if  it  is  pedunculated.  If 
it  is  situated  on  the  anterior  surface,  the  biceps  tendon  should  be  guarded, 
as  it  may  be  displaced  by  the  growth;  the  circumflex  nerve  is  also  to 
be  avoided.  Exostoses  are  occasionally  seen  on  the  shaft  referable  to 
traumatic  injury  of  the  periosteum  or  ossification  of  the  muscle,  par- 
ticularly the  brachialis.  Thorn-shaped  or  prickle-shaped  excrescences 
occur  on  the  humerus,  in  connection  with  such  on  many  other  bones 
(in  the  so-called  Stachelmenschen).  Bone  cysts  of  the  humerus  are  rela- 
tively benign  and  are  generally  softening-cysts.  They  may  be  multiple, 
appearing  at  different  points  on  the  skeleton,  as  noted  by  Virchow. 
Sonnenburg  saw  a  cyst  of  the  humerus  in  a  girl  of  twelve  years  result- 
ing apparently  from  a  fracture  received  five  years  previously;  there 
was  bulging  of  the  upper  third  of  the  humerus;  the  wall  of  the  cyst 
was  in  part  very  thin,  giving  "parchment  crackling"  and  containing 
bloody  serum.  The  entire  anterior  wall  was  excised  and  the  cyst 
excochleated. 

Aneurism. — Aneurism  of  the  bone  should  be  mentioned  at  this  point. 
According  to  the  reports  found  in  the  literature,  its  occurrence  cannot 
be  denied,  although  in  the  majority  of  instances  it  certainly  should  be 
regarded  as  a  myeloid  tumor  with  profuse  hemorrhage;  in  view  of  the 
relatively  favorable  prognosis  of  encapsulated  myeloid  sarcoma,  it  is 
not  improbable  that  the  tumor  would  yield  to  incision  and  tampon- 
ing. 

Echinococcus. — Echinococcus  occurs  with  apparent  predilection  in 
the  humerus;  at  least  among  33  instances  of  echinococcus  of  the  bones 
collected  from  the  literature  by  Reczey,  7  affected  the  humerus.  The 
diagnosis  is  usually  certain  only  after  the  cyst  has  ruptured  and  cysts 
have  been  discharged  from  the  medulla,  or  by  exploratory  operation. 

Sarcoma. — Sarcoma  is  the  most  frequent  malignant  tumor  of  the 
humerus  and  is  situated  usually  at  the  upper  end,  occasionally  in  the 
middle  third,  and  rarely  at  the  lower  end.  Gross,  who  states  that 
70  per  cent,  of  the  central  tumors  of  the  long  bones  are  sarcomata,  in 
165  cases  of  sarcoma  of  the  long  bones  found  25  of  the  humerus.  In  19 
cases  of  myelogenous  sarcoma,  Nasse  found  3  of  the  humerus;  among 
20  periosteal  sarcomata  he  found  5  of  the  humerus,  4  of  which  were 
at  the  upper  end.  The  growth  may  be  myelogenous  or  periosteal;  the 
first  variety,  which  is  encapsulated,  is  regarded  as  relatively  benign.    In 


152 


DISEASES  OE  THE  UPPER  ARM. 


general,  sarcoma  of  the  humerus  is  most  common  between  the  twenty- 
fifth  and  thirty-fifth  year  and  often  grows  rapidly.  Trauma  may  be  an 
exciting  cause,  and  according  to  the  statistics  extant  it  appears  that 
it  applies  more  to  sarcoma  of  the  extremities  than  to  malignant  tumors 
of  other  parts  of  the  body.  In  a  number  of  instances  the  growth  ap- 
peared in  the  callus  of  a  previous  fracture.  In  17  cases  of  callus 
tumors  Haberen  collected  8  of  the  humerus.  He  saw  a  laborer,  fifty- 
four  years  old,  wrho  had  been  run  over  and  received  a  comminuted 
fracture  at  the  junction  of  the  upper  and  middle  thirds;  it  healed  with 
a  normal  amount  of  callus;  one  month  later  there  were  severe  pains  at 

Fig.  94. 


Osteochondroma  of  humerus.     (Hull.) 


the  point  of  fracture;  eleven  months  later  there  was  a  tumor  the  size 
of  a  man's  head  which  encompassed  the  entire  periphery  at  the  lower 
third.  It  was  found  on  amputation  to  be  a  chondrosarcoma  with 
partial  mucoid  softening,  that  had  replaced  the  former  callus. 

Symptoms. — The  symptoms  at  first  are  often  merely  dull  pain  and 
slight  functional  disturbance,  or  they  may  be  absent.  The  rapid  appear- 
ance of  swelling  or  a  spindle-shaped  growth,  increasing  in  a  few  months 
to  the  size  of  a  fist  or  head,  soon  indicates  the  malignant  character  of 
the  disease.  A  dilated  network  of  veins  is  usually  visible  beneath  the 
stretched  skin;  the  tumor  not  infrequently  shows  points  of  discoloration 


DISEASES  OF  THE  HUMERUS. 


153 


or  pulsation  due  to  its  great  vascularity.     Spontaneous  fracture  is  not 
rare.     ( Fig.  95.) 

Diagnosis. — The  diagnosis  of  beginning  sarcoma  is  often  difficult. 
It  may  resemble  periostitis,  osteomyelitis,  or  tuberculosis,  particularly 
if  the  tumor  is  circumscribed,  gives  false  fluctuation  or  is  accom- 
panied by  high  or  varying  temperature,  a  not  infrequent  occurrence  if 
the  growth  is  rapid.  The  cases  in  which  the  joint  is  involved  at  an 
early  period  are  especially  difficult  to  diagnosticate.  As  to  the  differ- 
ential diagnosis  from  joint-affections,  in  sarcoma  the  centre  of  the 
swelling  lies  more  at  the  epiphysis  than  at  the  joint.    An  early  diagnosis 

Fig.  95. 


Sarcoma  of  the  humerus  with  spontaneous  fracture.     (Schreiber.) 


can  often  be  made  with  the  skiagraph.  (Fig.  96.)  Puncture  with  a  large 
needle  or  the  lancelet  often  gives  valuable  information  from  the  par- 
ticles of  tissue  and  their  histological  examination,  especially  in  the  case 
of  soft  tumors. 

Prognosis. — The  prognosis  is  favorable  only  for  the  lamellated, 
well-encapsulated  myelogenous  sarcoma;  if  curetted  out  or  resected, 
recovery  is  sometimes  possible.  All  other  forms  of  sarcoma  are  char- 
acterized by  great  malignancy  and  rapid  invasion  of  the  muscles  and 
veins;  they  may  spread  rapidly  and  diffusely  over  the  shoulder  and 


become  inoperable.     (Tig.  97.) 


154 


DISEASES  OF  THE  UPPER  ARM. 


Fig 


Carcinoma. — Carcinoma  of  the  humerus  occurs  secondary  to  carci- 
noma of  the  breast  or  primary  carcinoma  of  other  parts — for  example, 
the  thyroid,  as  noted  by  Eiselsberg.     The  growth  is  sometimes  ushered 

in  by  severe  pains;  occasionally 
the  first  symptom  is  a  sudden 
fracture.  Cases  of  epithelial  car- 
cinoma starting  in  old  necrosis- 
fistulas  of  the  humerus  are  re- 
ported. 

Treatment. — The  treatment 
of  malignant  tumors  of  the  hu- 
merus is  purely  operative,  and  in 
the  majority  of  instances  means 
amputation.  Resection  can  be 
considered  only  for  the  rare  cases 
of  benign,  encapsulated  giant-cell 
sarcoma  or  chondroma  of  the 
articular  end,  of  which  there  are 
numerous  instances  reported  in 
the  literature.  In  resecting  the 
upper  third  of  the  humerus  for 
sarcoma,  Wiesinger  made  a  flap 
corresponding  to  the  deltoid  with 
base  above.  Total  resection  is 
rarely  indicated  for  tumors  of 
the  humerus.  In  a  case  of  sar- 
coma developing  after  repeated 
fracture  of  the  arm  in  a  woman 
forty-seven  years  old,  Rotter  re- 
sected the  entire  humerus  and 
two-thirds  of  the  musculospiral 
nerve  through  an  incision  along 
the  great  vessels.  Amputation  at 
the  shoulder  is  indicated  for  the 
majority  of  malignant  tumors  of 
the  humerus.  Considering  the 
frequency  of  local  recurrence 
after  exarticulation  for  sarcoma 
— which  is  explained  by  Nasse  by  the  leaving  behind  of  microscopic 
portions  of  infiltrated  stumps  of  muscle — and  the  unfavorable  prog- 
nosis of  interscapulothoracic  amputation  when  done  secondarily,  Berger 
recommends  that  the  latter  operation  be  performed  at  the  outset.  In 
agreement  with  the  majority  of  recent  articles  the  author  can  only  add 
his  approval.  In  46  operations  of  this  kind  collected  by  Berger  there 
were  only  2  deaths — in  1  the  operation  could  hardly  be  held  responsible 
— so  that  Berger  assumes  a  mortality  of  5  per  cent.,  whereas  the  mor- 
tality attending  removal  of  the  shoulder-zone  when  done  secondarily  for 
recurrence  is  13  per  cent.;  in  addition,  the  number  of  recurrences  are 


Skiagram  of  a  sarcoma  of  the  humerus.     ( Fisk 


DISEASES  OF  THE  HUMERUS. 


155 


fewer,  hence  the  better  prospect  of  permanent  recovery,  for  in  33  per 
cent,  the  recovery  lasted  for  a  year  or  more.  Konitzer,  who  collected 
the  statistics  of  interscapulothoracic  amputation  up  to  1899,  estimates 
for  operations  for  tumors:  immediate  recovery,  96  percent.;  death  at 


Fig.  97. 


Sarcoma  of  the  humerus,     (v.  Bruns.) 


the  time  of  operation,  4  per  cent.;  recurrence,  21  per  cent.;  free  from 
recurrence  up  to  a  year,  34  per  cent. ;  free  from  recurrence  more  than 
a  year,  21  per  cent.;  recovered  without  report  as  to  later  condition, 
24  per  cent. 


CHAPTER    VII. 

OPERATIONS  OX  THE  UPPER  ARM. 
LIGATION  OF  THE  BRACHIAL  ARTERY. 

The  brachial  artery  can  be  ligated  in  the  internal  bicipital  groove 
throughout  the  length  of  the  upper  arm.  The  possibility  of  anomalies 
should  always  be  kept  in  mind;  one  of  the  most  frequent  is  the  division 
higher  up  into  two  branches,  the  one  following  the  normal  course  of 
the  brachial,  the  other  more  superficial  and  separated  from  it  laterally, 
running  with  the  basilic  vein;  or  the  division  may  be  high  up  and  the 
radial  and  ulnar  arteries  lie  beneath  the  skin.  Naturally  in  such  cases 
ligation  of  one  branch  would  not  be  sufficient. 

The  arm  is  abducted  and  semiflexed;  an  incision  H  to  2-j  inches 
long  is  made  through  the  skin  and  fascia  in  the  internal  bicipital  groove, 
the  inner  border  of  the  biceps  exposed  and  drawn  outward;  in  the 
middle  of  the  arm  the  median  nerve  lies  upon  the  artery,  higher  up 
it  lies  to  the  outer  side,  farther  down  to  the  inner  side.  The  artery  is 
accompanied  by  two  veins.  Gangrene  of  the  extremity  or  aneurism 
above  the  ligature  are  rare  sequelae. 

EXPOSURE  OF  THE  NERVES  OF  THE  UPPER  ARM. 

The  median  nerve  may  be  exposed  at  any  level  of  the  arm  at  the 
inner  border  of  the  biceps.  (Fig.  98,  C.)  The  nerve  accompanies  the 
brachial  artery,  in  the  upper  half  lying  to  the  outer  side,  in  the  lower 
half  to  the  inner  side  and  more  superficial. 

The  ulnar  nerve  is  best  found  through  a  longitudinal  incision  at  the 
point  given  in  Fig.  98,  .1,  the  breadth  of  two  ringers  above  the  internal 
epicondyle.  It  is  only  necessary  to  incise  the  skin  and  superficial 
fascia  behind  the  attachment  of  the  intermuscular  ligament.  The 
nerve  is  accompanied  by  the  collateral  ulnar  artery. 

The  musculospiral  nerve,  although  accessible  at  various  levels,  is 
most  frequently  exposed  at  the  point  where  it  crosses  the  outer  surface 
of  the  humerus,  exceptionally  higher  up  on  the  posterior  surface.  To 
find  the  nerve  below  the  middle  of  the  arm  on  the  outer  surface,  a 
two-inch  incision  is  made  midway  between  the  external  epicondyle  (B) 
and  the  deltoid  insertion  (C)  in  the  external  bicipital  groove.  (Fig.  99.) 
Exposing  the  tendinous  external  head  of  the  triceps  and  separating  the 
muscular  fibres  of  the  brachialis,  the  nerve  is  felt  as  a  firm  cord  which 
can  be  rolled  beneath  the  fingers.  The  nerve  lies  upon  the  bone;  to 
(156) 


PARTIAL  RESECTION  OF  THE  SHAFT  OF  THE  HUMERUS.     157 

its  radial  or  outer  side  lies  the  profunda  artery,  behind  it  the  musculo- 
cutaneous uerve  supplying  the  radial  side  of  the  posterior  surface  of  the 
forearm.  To  find  the  musculospiral  nerve  above  the  middle  of  the  arm 
on  the  posterior  surface,  die  incision  is  made  at  the  level  of  the  pos- 
terior axillary  fold  in  a  line  drawn  upward  from  the  tip  of  the  olecranon 
at  a  point  a  finger's  breadth  behind  the  posterior  border  of  the  deltoid 
close  to  the  long  head  of  the  triceps.      The  latter  is  easily  pulled  aside 


Fig.  98. 


Fig.  99. 


Incision  for  the  ulnar  (-4)  and  median  (C)  nerves. 
(Vogt.) 


Incision  for  the  musculospiral  nerve. 
(Vogt.) 


and  the  incision  carried  down  into  the  space  between  the  long  and  outer 
heads  of  the  triceps,  which  are  separated  from  each  other  bluntly  down 
to  the  bone.  The  nerve  lies  between  the  attachments  of  the  inner  and 
outer  heads  of  the  triceps  after  penetrating  the  long  head  of  the  triceps 
at  the  lower  border  of  the  latissimus;  the  profunda  artery  runs  in  front. 


PARTIAL  RESECTION  OF  THE   SHAFT   OF  THE  HUMERUS. 


The  path  through  which  the  shaft  of  the  humerus  is  reached  easily 
is  shown  by  an  interrupted  line  corresponding  above  to  the  groove 
between  the  pectoralis  and  deltoid,  farther  down,  to  the  external  bicipital 
groove,  and  from  this  point  running  to  the  external  epicondyle.  Due 
regard  for  the  musculospiral  nerve  prevents  the  incision  being  carried 
down  to  the  bone  in  the  entire  course  of  the  external  bicipital  groove.  On 
this  account  Larghi  advises  an  incision  in  the  bicipital  groove  above  or 
below  the  musculospiral;  the  bone  is  then  sawed  through  and  freed 


158  OPERA  TIOXS  OX  THE  UPPER  ABM. 

from  the  soft  parts  as  far  as  desired.  He  recommends  further  to  make 
two  incisions,  one  above  and  one  below  the  point  of  resection  and 
extraction;  to  divide  the  bone  at  both  ends  of  the  piece  to  be  resected 
without  exposing  its  middle  portion,  and  after  it  has  been  made  mov- 
able by  the  saw-cut  to  extract  it.  He  calls  this  the  tunnel  method. 
This  method  is  practicable  for  necrotomy  or  early  resection  in  acute 
osteomyelitis,  the  questionable  justification  of  which  latter  procedure 
will  not  be  discussed  here.  In  general  the  method  is  to  be  preferred 
which  allows  inspection  of  the  focus  in  its  entire  extent  before  resection. 
The  musculospiral  nerve  is  first  partially  exposed  (see  the  preceding 
section) — that  is,  it  is  left  partially  enclosed  in  the  muscles  and  care- 
fully retracted.  According  to  the  indication,  the  bone  is  exposed  and 
sawed  off  beneath  or  with  its  periosteum.  To  expose  the  entire  shaft, 
the  incision  is  prolonged  in  the  same  line  downward  to  the  epicondyle, 
upward  to  the  insertion  of  the  deltoid,  and  from  this  point  to  the  neck 
of  the  humerus  in  the  groove  between  the  deltoid  and  pectoralis.  The 
deltoid  is  lifted  off  at  its  insertion,  the  circumflex  nerve  and  artery 
exposed,  and  the  latter  tied.  The  technic  of  resection  of  the  upper 
end  of  the  shaft  and  head  is  the  appropriate  combination  of  the  above 
procedures  with  the  oblique  anterior  incision  employed  in  resection  of 
the  shoulder. 

AMPUTATION  OF  THE  UPPER  ARM. 

Various  incisions,  circular,  oval,  and  flap,  are  used;  the  one  generally 
preferred  is  the  circular  incision  in  two  stages.  Kocher  especially 
recommends  the  oblique  incision,  namely,  an  oblique  circular  incision 
with  its  upper  end  in  the  internal  bicipital  groove,  so  that  the  cicatrix 
does  not  lie  under  the  end  of  the  stump  as  in  the  ordinary  transverse  circu- 
lar incision.  Where  the  soft  parts  are  diseased  or  destroyed  higher  on  one 
side  than  on  the  other,  the  skin-flap  incision  permits  of  a  longer  stump. 
The  skin-flap  is  usually  taken  from  the  anterior  surface;  v.  Brims  uses 
only  the  skin  and  the  subcutaneous  tissue;  Kocher,  on  the  contrary, 
in  view  of  the  lateral  flattening  of  the  arm,  makes  the  flap  on  the  side. 
The  length  of  the  flap  should  be  the  same  as  the  diameter  of  the  arm, 
the  base  the  width  of  half  the  circumference.  One  can  also  make  a 
large  anterior  and  a  small  posterior  flap. 

The  arm  being  removed,  the  brachial  artery  and  veins  should  be 
found  and  tied  in  the  internal  bicipital  groove,  the  profunda  and  the 
accompanying  vein  tied  in  the  external  bicipital  groove,  and  the  ends 
of  the  nerves  shortened.  The  dressing  should  include  the  shoulder — 
spica. 

The  prognosis  of  amputation  of  the  upper  arm  as  such  is  absolutely 
favorable  at  the  present  time,  the  mortality  in  uncomplicated  cases 
being  practically  nil.  The  danger  lies  solely  in  local  or  general  compli- 
cations, especially  in  existing  sepsis.  Consequently  the  mortality  of 
amputation  for  trauma  varies  according  to  the  time  at  which  it  is  per- 
formed.    High  amputation,  if  it  is  possible,  is  much  to  be  preferred 


AMPUTATION  OF  THE  UPPER  ARM. 


159 


to  exarticulation  at  the  shoulder,  disregarding  the  severity  of  t he  oper- 
ation, because  of  the  value  of  a  small  stump  for  holding  objects  againsl 
the  chest. 

Prothesis  to  Replace  the  Amputated  Arm.  -The  question  of  com- 
pensating  for  the  loss  of  an  amputated  arm  by  artificial  apparatus  is  of 
(rreat  practical  importance.  Such  an  apparatus  should  nol  only  conceal 
the  deformity,  but  also  replace  as  far  as  possible  the  function  of  the  limb, 
and  the  surgeon  ought  to  interest  himself  more  in  tlii^  matter  than  has 
been  the  case  thus  far,  and  not  leave  it  entirely  to  the  limb-maker.    The 


Fig.  100. 


Fig.  101. 


Workinj;  prothesis.     (Le  Fort.) 


Nyrop's  working  prothesis. 


longer  the  stump,  the  more  suitable  it  is  for  a  prothesis.  The  position 
of  the  scar  should  have  regard  for  the  pressure  of  the  apparatus.  There- 
fore the  circular  incision  is  better  than  a  flap  incision.  The  longer  the 
lever-arm,  the  better  the  movements  of  the  apparatus  can  be  controlled 
by  the  other  limb  or  by  the  movements  of  the  shoulder  or  body.  For 
this  reason  the  usefulness  of  a  prothesis  decreases  with  the  height  of 
amputation;  in  amputation  of  the  forearm  active  flexion  and  extension 
of  the  elbow  are  retained,  and  supination  and  pronation  can  be  utilized 
for  the  movements  of  the  fingers.     An  artificial  arm  should  be  simple 


160  OPERATIONS  ON  THE  UPPER  ARM. 

in  construction,  easily  applied,  and  require  the  least  possible  repair.  It 
is  usually  made  of  sheaths  of  worked  leather,  formed  after  a  plaster  or 
wood  model,  with  some  sort  of  artificial  hand  attached,  and  is  hinged 
and  adjustable  at  the  elbow  by  means  of  lateral  metal  strips.  It  is  also 
jointed  at  the  shoulder  and  attached  to  a  shoulder-cap  or  jacket.  In 
general,  if  a  prothesis  is  needed  on  only  one  side,  a  substantial  artificial 
arm  which  can  be  adjusted  by  the  sound  hand  for  seizing  and  holding 
objects,  is  to  be  preferred  to  a  complicated  apparatus.  In  the  construc- 
tion of  the  limb  the  requirements  of  the  individual  case  will  always  be 
considered  and  complicated  apparatus  recommended  only  for  skilled 
laborers.  For  most  individuals  of  the  working  classes  the  so-called 
"work-arm"  is  best.  One  should  strive  to  obtain  solidity,  simplicity, 
cheapness,  and  durability  in  the  construction,  rather  than  the  conceal- 
ment of  the  deformity.  Rallif,  Van  Petersen,  Dalisch,  and  others  have 
devised  various  apparatus,  the  description  of  which  is  hardly  necessary 
here.  The  accompanying  illustrations  show  the  construction  of  Le  Fort's 
modification  of  Gripouilleau's  apparatus  (Fig.  100)  and  Xyrop's  "work- 
claw"  (Fig.  101).  It  is  beyond  question  that  many  kinds  of  work,  such 
as  digging,  plowing,  mowing,  threshing,  can  be  done  with  such  apparatus, 
although  the  zeal  and  intelligence  of  the  individual  concerned  are  im- 
portant factors;  particularly  where  the  deformity  is  bilateral  it  is  aston- 
ishing how  much  can  be  done  with  such  protheses.  Fven  those  with 
double  amputation  are  able  to  "  hold  their  own"  sometimes  in  agricul- 
tural work,  such  as  mowing,  loading,  etc.     (Schreiber.) 


MALFOKMATIONS,  INJURIES,  AND  DISEASES 
OF  THE  ELBOW  AND  FOREARM. 


By  Pbivat-docent  Db.  M.  WILMS. 


Anatomy  and  Mechanism  of  the  Elbow-joint.— The  elbow-joint 
is  composed  of  the  articular  surface  of  the  cubital  process  of  the  humerus, 
the  disk-shaped  depression  of  the  head  of  the  radius,  and  the  semilunar 
incisura  of  the  ulna.  The  head  of  the  radius  articulates  on  the  outer 
half  of  the  joint  with  the  outer  surface  of  the  ulna  in  the  incisura  radialis 
ulna?.  The  cubital  process  of  the  humerus  consists  of  the  external  con- 
dyle, whose  rounded  joint-surface,  the  capitulum  humeri,  articulates 
with  the  radius,  and  of  the  internal  condyle,  whose  joint-surface,  the 
trochlea,  is  partly  surrounded  by  the  incisura  semilunaris  of  the  ulna. 
From  each  condyle  projects  a  prominent  tuberosity,  the  external  and 
internal  epicondyles. 

The  motion  of  the  arm  at  the  elbow-joint  is  essentially  that  of  a  hinge. 
The  trochlea  produces,  however,  a  certain  amount  of  screw  action  in 
flexion  and  extension.  In  this  manner,  by  extension  of  the  arm  the 
normal  physiological  position  of  cubitus  valgus  is  produced,  the  axis 
of  the  arm  making  an  outward  open  angle  with  the  upper  arm. 

In  complete  extension  the  olecranon  meets  a  resistance  in  the  fossa 
on  the  posterior  surface  of  the  humerus.  In  flexion  the  coronoid  process 
strikes  against  the  coronoid  fossa  on  the  anterior  surface  of  the  humerus. 
In  adults  the  arc  from  full  flexion  to  full  extension  is  about  150  degrees. 

Abduction  and  adduction  in  the  elbow-joint  are  prevented  by  the 
reinforcing  ligaments  on  the  inner  and  outer  side  of  the  capsule.  Of 
these,  the  internal  lateral  ligament  (ligamentum  collaterale  ulnare)  is 
attached  above  to  the  internal  condyle  and  epicondyle,  below  to  the 
ulna;  the  external  lateral  ligament  (ligamentum  collaterale  radiale)  is 
attached  above  to  the  external  condyle  and  epicondyle;  below,  it  blends 
with  the  annular  ligament  surrounding  the  head  of  the  radius,  and  is 
thus  indirectly  attached  to  the  outer  side  of  the  ulna. 

The  external  lateral  ligament  (ligamentum  annulare  radii)  permits  of 
the  necessarily  free  rotary  movement  of  pronation  and  supination  of  the 
radius  in  that  it  is  not  connected  directly  with  the  radius,  the  latter  with 
its  neck  lying  between  the  bands  of  the  ligament  like  a  button  in  a 
button-hole.  Impairment  of  free  rotation  of  the  head  of  the  radius  in 
the  elbow-joint  thus  hinders  pronation  and  supination  of  the  forearm. 
The  arc  of  pronation  and  supination  of  the  hand  in  the  adult  is  about 
Vol.  III.— 11  (  161  ) 


162    MALFORMATIONS  AND  DISEASES  OF  ELBOW  AND  FOREARM. 

150  to  160  degrees.  The  cheeking  of  this  motion  depends  essentially 
upon  the  degree  of  tension  which  exists  in  the  ligaments  between  the 
bones  of  the  forearm  at  their  upper  and  lower  articular  ends.  The 
contact  between  the  two  bones  of  the  forearm  as  observed  upon  the 
cadaver  during  full  pronation  and  supination  does  not  take  place  in  the 
living  subject. 

The  epiphyseal  lines  of  the  humerus  and  of  the  bones  of  the  forearm 
lie  within  the  joint — that  is,  inside  of  the  capsular  attachments — a  fact 
of  great  importance  on  account  of  the  frequency  of  injuries  and  diseases 
of  the  elbow  in  children.  The  author  will  return  later  to  the  development 
of  the  epiphyses  in  considering  the  fractures  of  the  elbow-joint.  The 
lines  of  attachment  of  the  capsule — that  is,  the  line  of  demarcation  of 
the  joint  cavity  upon  the  humerus — are  as  follows: 

The  epicondyles  and  adjacent  surfaces  of  the  condyles  lie  outside  of 
the  capsule.  Between  these  two  points  the  capsule  extends  upward  on 
the  anterior  and  posterior  surfaces  of  the  humerus  to  a  point  in  the 
middle  line  above  the  coronoid  and  olecranon  fossas.  On  the  forearm, 
as  already  mentioned,  the  head  and  neck  of  the  radius  lie  within  the 
capsule. 

On  the  ulna,  on  the  other  hand,  only  the  incisura  semilunaris  and 
incisure  radialis  lie  within  the  capsule,  the  posterior  surface  of  the 
olecranon  being  extracapsular.  Corresponding  to  this  arrangement  of 
the  capsule,  intra-articular  extravasations  and  hemorrhages  will  be  most 
apparent  where  the  capsule  approaches  the  surface — that  is,  at  either 
side  of  the  olecranon  behind,  where  two  elongated  swellings  are  visible 
in  extravasation  or  inflammatory  processes  in  the  joint;  also  below  the 
internal  epicondyle,  and  especially  above  the  head  of  the  radius  below 
the  external  epicondyle.  In  inflammatory  affections  of  the  capsule  and 
synovialis  a  characteristic  point  of  sensitiveness  is  present,  particularly 
at  these  two  latter  points,  for  here  the  diseased  synovial  membrane  can 
be  compressed  against  the  underlying  bone,  the  head  of  the  radius.  Dur- 
ing flexion  the  capsule  is  thrown  into  folds  upon  the  anterior  surface  of 
the  humerus;  during  extension  upon  the  posterior  surface. 


CHAPTER  VIII. 

DEFECTS  OF  THE  FOREARM  AND  MALFORMATIONS  OF  THE 

ELBOW-JOINT. 


The  gross  disturbances  in  growth  and  the  arrest  in  development  of 
the  arm  are  only  of  subordinate  interest  for  the  practising  surgeon.  The 
disturbances  in  development  known  as  phocomelus  and  hemimeles  may 
be  due  to  faulty  construction  of  the  ovum  or  result  from  constriction 
produced  by  amniotic  growths  and  bands.  An  interesting  example  of 
the  latter  is  presented  in  Fig.  102,  defect  of  the  forearm.  The  hand  is 
recognizable  as  a  rudimentary  projection  upon  the  stump.  This  rudi- 
ment is  movable  and  is  able  to  seize  objects,  as  shown.    Upon  the  top 


Fig.  102. 


Fig.   103. 


Congenital  defect  of  the  forearm  and  hand 
due  to  constriction  of  amniotic  bands.  Man 
aged  twenty  years.     (Trendelenburg.) 


.Y-ray  of  Fig. 


of  the  stump  is  seen  the  cicatrix  produced  by  amniotic  adhesions.  The 
proof  that  such  malformations  do  not  arise  from  defects  in  construction 
is  shown  by  the  x-ray  picture  of  this  malformation  (Fig.  103),  in  which 
the  radius  and  ulna  are  normal  up  to  the  point  of  constriction ;  both  bones 
appear  as  if  amputated. 

The  only  task  which  concerns  the  surgeon  in  such  defects  is  to  conceal 
the  deformity  and  make  it  useful  to  the  patient  by  some  mechanical 
apparatus.  As  mention  will  be  made  later  of  the  more  important  points 
concerning  such  apparatus  in  considering  the  hand,  it  will  be  sufficient  to 
indicate  here  that  the  present  tendency  is  to  do  away  with  very  compli- 
cated contrivances  and  use  only  the  more  simple  and  durable  apparatus. 

I  163) 


164 


MALFORMATIONS  OF  THE  ELBOW-JOIST. 


Fig.  104. 


In  regard  to  the  special  forms  of  anomalies  in  development,  it  is  suffi- 
cient to  note  the  fact  that  rare  cases  of  congenital  dislocation  of  both 
bones  of  the  forearm,  both  backward  and  forward,  have  been  seen. 

Congenital  dislocations  of  the  radius  have  been  more  frequently 
reported.  Ronnenberg  collected  31  cases  of  this  sort  in  part  of  which 
there  was  a  certain  heredity.  In  several  cases  the  affection  involved 
both  arms;  partial  development  of  the  radial  articulation  of  the 
humerus  and  of  the  head  of  the  radius  and  the  even  more  frequent 
absence  of  the  articular  cartilage  indicate  a  disturbance  early  in  em- 
bryonal life.  The  head  of  the  radius  is  usually  dislocated  backward. 
The  movements  of  the  arm  are  only  slightly  impaired.  The  radius  is 
usually  longer  than  the  ulna. 

The  most  practical  operative  measure  in  connection  with  congenital 
dislocations  of  the  head  of  the  radius  is  resection  of  the  capitulum  radii, 
which  will  be  discussed  later  under  acquired  dislocations.  The  relatively 
slight  functional  disturbance  makes  it  necessary  only  in  a  few  cases. 

Cubitus  varus  and  valgus  are  the  terms  applied,  according  to  the 
analogy  of  the  disturbances  in  the  development  of  the  knee-joint,  to  the 
conditions  in  which  the  axis  of  the  forearm  di- 
verges more  or  less  from  the  prolongation  of 
the  axis  of  the  upper  arm.  Cubitus  varus  and 
valgus  occur  congenitally,  and  are  occasioned 
by  a  relaxed  condition  of  the  articular  liga- 
ments, by  extension  and  especially  by  hyper- 
extension;  it  is  frequently  possible  for  a  partial 
dislocation  to  be  produced.  In  these  cases 
heredity  plays  an  important  part. 

Cubitus  valgus  and  varus  may  arise  in  the 
course  of  post-natal  growth  from  premature  os- 
sification of  one  or  the  other  of  the  upper  epi- 
physeal lines  of  the  bones  of  the  forearm  pro- 
ducing an  inequality  in  the  length  of  the  two 
bones  and  a  consequent  abnormal  attitude  of 
the  forearm. 

The  normal  so-called  physiological  cubitus 
valgus  as  described  by  Mikulicz  is  an  impor- 
tant consideration  in  the  analysis  of  these  anom- 
alies. According  to  Htibscher's  investigations, 
this  physiological  cubitus  valgus  is  less  frequent 
in  men  than  in  women.  Taking  the  angle  a 
(Fior.  104)  made  by  the  axis  of  the  forearm  and 
the  prolongation  of  the  axis  of  the  upper  arm, 
the  so-called  complementary  angle,  as  the  standard  of  measurement, 
the  physiological  cubitus  valgus  shows  an  average  variation  in  men  of 
from  1  to  9  degrees;  in  women,  of  from  15  to  25  degrees.  Hubseher 
discovered  that  this  physiological  increase  of  valgus  position  took  place 
not  in  childhood,  but  after  puberty.  The  reason  for  this  deviation  is  not 
to  be  found  in  the  elbow-joint  itself,  but  rather  in  the  outward  deflection 


Physiological  cubitus  valgus 
in  female,  a  =  20  degree*,  the 
complementary  angle. 


MALFORMATIONS  OF  THE  ELBOW-JOIST.  1G5 

of  the  lower  third  of  the  diaphysis  of  the  humerus.  This  is  character- 
istic for  the  female  forearm,  in  that  the  arm  is  forced  into  this  position 

by  the  narrowness  of  the  shoulders  as  compared  with  the  breadth  of 
the   pelvis. 

Traumatic  cubitus  varus  and  valgus  will  be  considered  under  frac- 
tures of  the  elbow-joint.  It  should  be  mentioned  here,  however,  that 
cubitus  valgus  may  result  from  injury  to  the  epiphyseal  line  of  the 
humerus  and  the  consequent  disturbance  in  growth.  More  frequently, 
however,  it  follows  a  supracondyloid  fracture  (fractura  supracondylica) 
or  fracture  of  the  external  condyle.  Cubitus  varus  may  result  from 
malunion  of  a  fracture  of  the  internal  condyle. 

Slight  cubitus  valgus  and  varus  do  not  require  operative  treatment. 
The  more  severe  forms  may  be  corrected  by  a  wedge-shaped  resection 
in  the  lower  third  of  the  shaft  of  the  humerus.  The  chief  task  is  natu- 
rally to  prevent  deformity  by  securing  proper  union  of  the  fracture. 


CHAPTEK   IX. 

INJURIES  OF  THE  ELBOW-JOINT. 

CONTUSION  OF  THE  ELBOW-JOINT. 

Contusion  of  the  elbow-joint  results  from  direct  violence  upon  the 
region  of  the  joint,  and,  disregarding  the  lesions  of  the  soft  parts,  pro- 
duces lesser  injuries  of  the  exposed  bony  parts,  the  olecranon,  condyles, 
and  epicondyles. 

It  may  be  difficult  under  circumstances  to  exclude  with  certainty  the 
existence  of  slight  fissures  in  the  bone.  As  the  x-ray  investigation  has 
taught,  they  occur  much  more  frequently  than  was  formerly  believed. 
The  movements  of  the  joint  are  slightly  painful,  but  not  limited. 
Extravasation  of  the  blood  in  the  joint  is  usually  slight. 

Diagnosis. — It  is  a  safe  rule  to  make  the  diagnosis  of  contusion  only 
after  the  most  careful  examination  of  the  bone  has  excluded  the  possi- 
bility of  fracture  or  fissure.  The  swelling  of  the  joint  due  to  hsemar- 
throsis  is  often  concealed  by  periarticular  swelling  of  the  soft  parts, 
nevertheless  an  intra-articular  effusion  of  serum  or  blood  is  recogniz- 
able, corresponding  to  the  normal  contour  of  the  capsule,  at  both  sides 
of  the  olecranon,  upon  the  posterior  surface  of  the  condyles  and  above 
the  head  of  the  radius. 

Treatment. — The  treatment  of  contusion  consists  in  rest  for  several 
days,  according  to  the  severity  of  the  injury.  Wet  dressings  and  press- 
ure, elevating  the  elbow  upon  a  pillow,  and  applying  an  ice-bag  or  hot- 
water  bag  check  the  swelling  and  diminish  pain.  Care  should  always 
be  exercised  that  the  ice-bag  or  hot-water  bag  does  not  come  in  contact 
with  the  skin,  as  gangrene  or  serious  burns  may  result. 

SPRAINS  OF   THE  ELBOW- JOINT. 

By  sprain  is  meant  an  injury  of  the  capsule  and  of  the  ligaments, 
produced  by  forced  movements,  either  hyperextension,  ulnar  adduction, 
radial  abduction,  or  violent  pronation  and  supination.  Hyperextension 
often  produces  a  backward  dislocation  of  the  forearm  (luxatio  anti- 
brachii).  This  backward  luxation,  however,  may  not  be  complete,  but 
instead  the  hyperextension  may  produce  merely  laceration  of  the  anterior 
wall  of  the  capsule,  and  finally  laceration  of  the  lateral  ligaments  with- 
out displacement  of  the  joint-surfaces.  This  form  of  laceration  of  the 
capsule  and  ligaments  is  the  one  most  frequently  observed.  Some  of 
the  forms  of  sprain  have  the  same  etiology  as  backward  dislocation. 

Swelling  of  the  soft  parts  occurs  at  the  points  corresponding  to  the 
lesions  of  the  capsule  and  ligaments,  and  if  diffuse  involves  the  entire 
(  166) 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     167 

region  of  the  joint.  Intraarticular  hemorrhage  often  increases  the 
swelling.  In  the  case  of  a  simple  sprain  the  movements  of  the  joint 
are  only  slightly  impaired.  Extension  of  the  forearm  is  painful  from 
the  tension  upon  the  injured  anterior  wall  of  the  capsule.  Abnormal 
mobility  rarely  occurs  in  sprains  about  the  elbow-joint,  in  contrast  to 
those  of  the  knee-joint,  in  which,  as  the  result  of  laceration  of  the  lateral 
ligaments,  genu  varum  or  valgum  is  easily  produced. 

Diagnosis. — The  diagnosis  of  sprain  is  to  be  made  only  if,  after  careful 
examination,  every  lesion  of  the  bones  can  be  excluded.  Slight  bone 
injuries,  such  as  avulsion  of  the  coronoid  process  of  the  ulna  or  of  the 
epicondyles,  are  easily  concealed  by  marked  swelling  of  the  soft  parts. 
It  is  here  that  examination  with  the  x-ray  is  particularly  valuable;  in 
fact,  is  more  valuable  for  the  elbow-joint  than  any  other  articulation. 
The  amount  of  swelling  and  ecchymosis  is  not  conclusive  for  the  diag- 
nosis, as  they  vary  greatly.  Swelling  due  to  laceration  of  the  muscles 
and  tendons  in  the  region  of  the  elbow-joint  may  make  the  diagnosis 
difficult.  For  the  differential  diagnosis  of  sprain  from  intra-articular 
fracture,  careful  palpation  and  determination  of  the  bony  parts  are 
important;  secondarily  the  slight  functional  disturbance  verified  by 
executing  slow  movements  of  the  arm. 

Prognosis. — The  prognosis  of  sprain  with  extensive  laceration  of  the 
capsule  and  the  ligaments  is  frequently  a  doubtful  one.  For  although 
abnormal  looseness  of  the  joint  may  persist  in  a  few  cases,  more  fre- 
quently stiffness  is  apt  to  follow  simple  sprain  in  consequence  of  intra- 
articular adhesions  and  cicatricial  induration  of  the  capsule,  ligaments, 
and  surrounding  soft  parts,  especially  in  old  individuals. 

Treatment. — In  the  treatment  of  recent  injuries  of  the  elbow-joint, 
particularly  in  children,  it  is  advisable  in  the  presence  of  marked  swelling 
to  make  a  thorough  examination  under  anaesthesia.  Every  bony  promi- 
nence should  be  palpated  systematically  and  the  results  compared  with 
the  normal  relations  in  the  sound  arm,  and  if  necessary  with  an  anatom- 
ical specimen.  In  the  average  case,  rest  for  about  eight  days  is  advisable. 
During  this  time  light  massage,  later  combined  with  warm  baths,  aids 
resorption  of  the  extravasation.  At  the  end  of  eight  days  gentle  move- 
ments, gradually  increased  until  full  motion  is  obtained  in  the  third  or 
fourth  week.  It  is  important  to  continue  this  after-treatment  for  some 
time  to  prevent  secondary  shrinkage  and  contractures,  as  the  latter  may 
develop  at  a  late  period. 


FRACTURES  OF  THE  ENDS  OF  THE  BONES  FORMING  THE 
ELBOW-JOINT. 

Fractures  at  the  Elbow-joint. 

Diagnostic  Examination. — The  complicated  anatomical  and  mechan- 
ical relations  of  the  elbow-joint  present  many  difficulties  in  the  diagnosis 
of  bone  fractures  involving  this  joint.    In  every  injury  of  the  elbow-joint 


168  INJURIES  OF  THE  ELBOW-JOINT. 

suspicious  of  fracture,  the  examination  should  be  made  in  a  somewhat 
typical  manner,  applicable  generally  to  the  individual  fractures  to  be 
described  later  on,  as  follows: 

The  upper  part  of  the  body  is  stripped  in  order  to  compare  the  sound 
with  the  injured  arm.  The  surgeon  obtains  by  inspection  the  relation 
of  the  forearm  to  the  upper  arm,  the  presence  of  any  shortening  of  the 
forearm,  the  position  of  the  hand.  Further,  the  posture  of  the  body, 
and  the  way  in  which  the  injured  arm  is  supported  by  the  sound  one,  is 
of  interest.  Also  the  presence  of  swelling,  the  anteroposterior  and  trans- 
verse diameters  of  the  joint,  visible  contusions,  ecchymosis,  wounds, 
and  finally  the  subjective  pain  at  the  time  of  the  accident  and  afterward. 

After  obtaining  the  history  and  inspecting  the  limbs,  palpation  is 
necessary  to  determine  the  position  of  certain  fixed  points.  It  is  advis- 
able first  to  acquaint  one's  self  with  the  position  of  these  fixed  points 
on  the  sound  arm. 

Palpation  of  the  elbow-joint  in  the  absence  of  swelling  of  the  soft  parts 
gives  four  bony  points;  three  of  these  (the  olecranon, internal  epicondyle, 
and  external  epicondyle)  lie  in  a  straight  line  with  the  arm  extended; 
with  the  arm  flexed  they  form  the  three  points  of  the  triangle  seen  in 
Fig.  105.     The  normal  position  of  these  three  points  upon  the  sound 

Fig.  105. 


Line  joining:  the  epicondylea  and  olecranon  process,  with  the  arm  extended  (a)  and  flexed  (6). 


arm  should  be  referred  to  constantly  for  comparison.  The  fourth  point, 
the  head  of  the  radius,  is  palpable  from  T3¥  to  -f  of  an  inch  below — 
that  is,  toward  the  hand  from  the  external  epicondyle — if  pronation 
and  supination  of  the  forearm  are  possible  and  not  too  painful.  By 
rotating  the  hand  one  can  feel  the  head  of  the  radius  revolving  beneath 
the  fingers. 

Having  ascertained  the  position  of  the  above  fixed  points,  and 
the  existence  of  any  change  of  relation  between  them,  the  surgeon 
examines  for  points  of  tenderness  and  crepitus,  the  limits  of  active  and 
passive  motion  of  the  joint — that  is,  normal  extension,  flexion,  prona- 
tion and  supination — finally,  abnormal  hyperextension  or  lateral  adduc- 
tion and  abduction. 

In  adults  all  these  data  may  be  obtained  in  cases  of  slight  injury 
of  the  elbow-joint  without  the  aid  of  narcosis,  by  carrying  out  careful 
movements  of  the  arm.     As  a  rule  anaesthesia  is  necessary  to  make  an 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     169 

accurate  diagnosis,  as  a  complete  examination  of  the  mobility,  especially 
abnormal  mobility,  is  impossible  on  account  of  the  pain.  In  children, 
who  constitute  the  greater  contingent  with  reference  to  the  injuries  of 
the  elbow-joint  in  question,  narcosis  is  necessary  and  advisable  in  almost 
all  cases.  In  children,  furthermore,  not  only  is  the  examination  hin- 
dered by  the  restlessness  of  the  patient,  but  the  smallness  of  the  bones 
and  the  often  marked  swelling  also  make  diagnosis  rather  difficult. 
The  surgeon  should  not  be  satisfied  with  a  superficial  examination  in 
children  if  the  examination  is  not  easy,  as  the  elbow-joint  in  all  cases 
demands  an  accurate  diagnosis,  since  the  treatment  can  and  must  vary 
considerably  according  to  the  form  of  the  fracture.  A  certain  classifica- 
tion for  the  better  understanding  of  the  individual  forms  of  the  frac- 
tures of  the  ends  of  the  bones  forming  the  joint  is  of  advantage.  The 
surgeon  must  remember,  however,  that  the  fracture-lines  given  here 
vary  considerably  and  are  capable  of  many  combinations. 

Fractures  of  the  Lower  End  of  the  Humerus. 

Surgeons  distinguish  the  following  fractures  of  the  lowTer  end  of  the 
humerus,  to  be  considered  in  order: 

1.  Fractura  supracondylica  (supracondyloid  fracture). 

2.  Fractura  supracondylica  with  longitudinal  fracture  betwreen  the 

condyles,  T-  or  Y-shaped  fracture. 

„  .  ,.  f  externalis. 

3.  Fractura  condyh  |  lateraUg 

4.  Fractura  epicondyli  lateralis. 

_    ^,  .        i  ,-  f  internalis. 

5.  b  ractura  epicondyli  <         r  r 

1  J     {  medians. 

6.  Fractura  condyli  medialis. 

7.  Fractura  diacondylica. 

8.  Fractura  capituli  humeri. 

Supracondyloid  Fracture  of  the  Humerus. — The  fracture-line  lies, 
as  the  name  indicates,  above  the  condyles  and  epicondyles  in  the 
lower  end  of  the  shaft.  In  the  simple  form  the  fracture-line  lies  en- 
tirely without  the  joint-capsule.  The  fracture  is  seldom  transverse, 
as  shown  in  the  a;-ray  picture.  (Fig.  10G.)  Usually  it  is  oblique,  as  a 
posterior  fragment  of  the  lower  end  of  the  diaphysis  generally  breaks 
off  with  the  processus  cubitalis.  In  this  way  the  line  of  fracture  is 
higher  behind  than  in  front.  In  Fig.  107  the  .r-ray  shows  the  usual  line 
as  it  exists  in  several  typical  pictures  in  the  author's  possession. 

Cause  and  Mechanism  of  Origin. — The  fracture  is  usually  produced 
by  hyperextension  of  the  elbow-joint  from  a  fall  upon  the  surface  of 
the  outstretched  hand,  the  arm  being  abducted.  In  this  manner  the 
joint-capsule  is  drawn  tightly  over  the  anterior  surface  of  the  lower  end 
of  the  humerus  and  snaps  off  the  articular  portion  backward.  Fracture 
can  only  occur  when  the  capsule,  as  in  young  children,  has  a  greater 
power  of  resistance  than  the  bone  and  therefore  cannot  be  torn.  If 
the  anterior  portion  of  the  capsule  tears  because  the  bone  has  the  greater 


170 


INJURIES  OF  THE  ELBOW-JOINT. 


power  of  resistance,  as  is  usually  the  case  in  older  children,  a  posterior 
dislocation  occurs  as  a  result  of  hyperextension.  Supracondvloid  frac- 
tures in  early  childhood  and  the  backward  dislocation  frequently  seen 
from  the  tenth  to  the  fifteenth  year  are  therefore  etiologically  closely 
related.  The  supracondyloid  fracture,  however,  is  not  confined  to 
children,  as  it  can  be  produced  in  adults  by  different  forms  of  trauma, 
such  as  machinery  accidents,  fly-wheel  injuries,  by  hyperextension  and 
rotation. 

The  same  action  as  produced  by  a  fall  upon  the  hand  with  the  arm 
extended  or  slightly  flexed  may  be  effected  by  a  blow  or  push  upon  the 


Fig.   106. 


Fig.  107. 


Supracondyloid  fracture  of  the  humerus, 
rare  transverse  fracture. 


Supracondyloid  fracture  of  the  humerus, 
usual  form. 


posterior  surface  of  the  humerus  with  the  forearm  fixed.  The  humerus 
is  thus  driven  forward.  The  fracture-line  is  usually  the  same  as  seen 
in  Fig.  107. 

A  second  but  less  frequent  form  of  fractura  supracondylica  is  described 
by  Kocher  as  "fracture  by  flexion."  It  is  explained  by  the  normal 
position  of  the  processus  cubitalis  of  the  humerus,  which,  it  will  be 
remembered,  is  bent  slightly  forward.  A  direct  blow  or  push  upon 
the  posterior  surface  of  the  ulna  transmitted  to  the  process  in  the  long 
axis  of  the  humerus  would  drive  the  process  forward.  In  contrast  to 
the  first  and  more  frequent  form,  the  fracture-line  is  oblique  in  the 
opposite  direction,  so  that  it  lies  higher  upon  the  anterior  surface  than 
on  the  posterior.     (Fig.  108.) 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     IJ\ 


These  types  of  fracture,  whose  etiology  is  essential  for  a  knowledge 
of  such  fractures,  are  not  only  of  theoretical  interest,  hut  also  determine, 
according  to  the  direction  of  the  fracture-line,  both  the  symptomatology 
and  the  treatment.  For  example,  in  the  first  case,  in  fracture  by  hyper- 
extension  (Fig.  107),  the  lower  fragment  is  easily  pushed  backward, 
while  in  fracture  by  flexion  (Fig.  108)  such  a  displacement  is  impossible. 
The  danger  of  damage  to  the  soft  parts  about  the  elbow  is  greater  in  the 
first  than  in  the  second  type  of  fracture  because  the  upper  fragment 
may  easily  perforate  forward. 

Symptoms. — In  the  common  form  of  fractura  supracondylica  the 
forearm  and  lower  fragment  of  the  humerus  are  usually  forced  back- 
ward; the  upper  fragment  projects  forward  and  presses  against  the  soft 
parts  in  front  of  the  elbow.  On  inspection  of  the  injured  arm  from  the 
side,  if  a  typical  displacement  of  the  fragments  exists,  one  observes  an 
angular  deviation  in  the  axis  of  the  upper  arm  above  the  elbow,  which 


Fig.  108. 


Fig.   109. 


Supraeondyloid  fracture  (flexion  fracture). 


The  inflexion  in  the  axis  of  the  humerus  in  the 
usual  form  of  supraeondyloid  fracture. 


may  be  concealed  in  recent  injuries  by  swelling,  ecchymosis,  and  extrav- 
asation. The  upper  arm  forms  an  obtuse  angle  opening  backward,  as 
indicated  diagrammatic-ally  in  Fig.^109.  With  this  displacement  of  the 
lower  fragment  the  contour  of  the  posterior  surface  of  the  upper  arm 
above  the  joint  is  concave  backward,  like  the  deformity  in  backward 
dislocation  of  the  forearm. 

By  the  examination  the  position  of  the  fixed  bony  points  is  determined; 
the  olecranon,  external  and  internal  epicondyles,  and  the  head  of 
the  radius  are  in  their  normal  position.  By  accurate  palpation  frac- 
ture tenderness  is  obtained  above  the  joint,  not  at  the  prominent  points 
mentioned.  In  the  crease  of  the  elbow  one  often  feels  the  sharp  edge  of 
the  upper  fragment  of  the  humerus  pressing  against  the  soft  parts. 

The  mobility,  best  determined  under  anaesthesia,  especially  in  children, 
is  conclusive  for  the  diagnosis  of  fracture,  particularly  in  contrast  to 
dislocation.    The  angular  deformity  of  the  upper  arm  and  displacement 


172  INJURIES  OF  THE  ELBOW-JOIST. 

are  easily  overcome  by  traction  upon  the  forearm.  Under  certain  cir- 
cumstances they  may  as  easily  return.  This  is  diagnostic  for  fracture 
against  dislocation.  Manipulation  usually  elicits  crepitus.  Flexion  of 
the  elbow-joint  is  considerably  limited  if  there  is  forward  displacement 
of  the  upper  fragment,  as  in  flexion  the  bones  of  the  forearm  press 
against  the  projecting  upper  fragment.  Under  narcosis,  on  the  other 
hand,  hyperexiension  is  easy.  Abnormal  lateral  movements,  abduc- 
tion and  adduction,  are  possible,  and  thus  the  production  of  a  cubitus 
valgus  and  varus.  Rotation  of  the  hand  is  not  necessarily  impaired. 
The  hand  is  usually  supinated  by  the  biceps,  the  supinator  of  the  fore- 
arm when  the  same  is  flexed,  in  order  to  relax  as  far  as  possible  the 
tension  produced  by  the  projecting  upper  fragment.  The  other  hand 
usually  supports  the  affected  arm  in  a  characteristic  manner  to  prevent 
motion  and  pain.  The  elbow-joint  of  the  affected  arm  is  usually  bent 
at  an  obtuse  angle. 

Diagnosis. — From  the  above  symptoms  the  diagnosis  of  supracondy- 
loid  fracture  is  usually  not  difficult,  particularly  when  aided  by  an 
examination  under  anaesthesia.  The  fracture  is  not  necessarily  accom- 
panied by  any  displacement  of  the  lower  fragment  such  as  is  indicated  in 
the  .r-ray  picture.  (Fig.  107.)  A  serrated  transverse  fracture  may  prevent 
any  displacement  of  the  fragments.  In  this  case,  however,  the  false 
mobility  of  the  lower  end  of  the  humerus  is  easily  demonstrable.  There 
can  be  no  likelihood  therefore  of  confusing  the  condition  with  disloca- 
tion of  the  elbow  in  either  case.  Grasping  the  epicondyles  between  the 
thumb  and  first  finger,  and  the  humerus  above  with  the  other  hand, 
false  motion  is  easily  obtainable  and  one  can  feel  the  shifting  of  the 
lower  fragment,  accompanied  usually  by  crepitus.  In  supracondyloid 
fracture  by  direct  violence  the  vessels  and  nerves  of  the  elbow  region 
may  be  involved.  The  author  mentions  here  particularly  the  not  very 
infrequent  injury  of  the  cubital  artery  and  median  nerve  at  the  elbow 
by  the  projecting  upper  fragment.  Under  certain  circumstances  the 
fragment  may  perforate  the  soft  parts  and  produce  a  compound  frac- 
ture. Perforation  of  the  ends  of  the  fragments  upon  the  posterior  surface 
is  relatively  infrequent,  and  is  possible  only  in  fracture  by  flexion,  in 
which  the  upper  fragment  may  perforate  downward  and  backward. 

The  symptoms  of  fracture  by  flexion  are  the  same  as  those  of  supra- 
condyloid fracture,  except  for  the  absence  of  backward  displacement 
of  the  lower  fragment. 

Treatment. — The  great  variation  in  the  direction  and  the  numerous 
combinations  of  the  lines  of  fracture  about  the  elbow-joint  preclude  the 
possibility  of  a  uniform  method  of  treatment  for  all  fractures.  This 
circumstance  and  the  complicated  structure  of  the  elbow-joint  are  often 
the  cause  of  severe  disturbances,  which  demand  as  the  first  essential  of 
treatment  that  the  direction  of  the  fracture  should  be  carefully  taken 
into  consideration.  It  is  necessary  therefore  to  describe  in  connection 
with  every  form  of  fracture  the  corresponding  best  method  of  treatment, 
in  spite  of  the  slight  repetitions  thereby  involved.  The  diagnostic 
possibilities  presented   in   the   methods   of   examination    by  means  of 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     173 

the  cathodic  currents  demonstrating  the  presence  of  injuries  and  tears 
so  small  as  to  escape  detection  in  the  ordinary  examination,  will  cer- 
tainly present  a  field  for  the  operative  treatment  of  .fractures  barely 
touched  upon  at  the  present  time. 

As  mentioned,  supracondyloid  fracture  in  the  average  case  pre- 
sents a  typical  backward  displacement  of  the  lower  fragment.  To 
reduce  this  displacement  under  an  anaesthetic,  if  necessary  by  direct 
pressure  and  traction,  and  to  adapt  the  fragments  in  the  best  possible 
position,  is  the  surgeon's  first  task;  retention  in  the  normal  position  is 
the  chief  purpose  of  the  splint.  The  splint  commonly  used  for  frac- 
ture of  the  elbow  is  the  circular  or  two-strip  plaster-of-Paris  splint, 
with  the  forearm  semiflexed.  The  choice  of  the  splint  to  be  used, 
however,  will  be  determined  by  the  peculiarities  of  each  fracture.  The 
extension  splint  is  being  more  and  more  applied  to  fractures  of  the  elbow. 
The  circular  plaster  splint  has  the  disadvantage  of  producing  constric- 


Fig.  110. 


Fig.  111. 


Beely's  plaster-of-Paris  strip  splint. 


tion  and  even  pressure-necrosis  or  gangrene  in  the  event  of  post- 
traumatic swelling  or,  if  applied  upon  a  swollen  arm,  of  allowing  second- 
ary displacement  of  the  fragments  after  the  swelling  has  subsided.  For 
this  reason  the  two-strip  splint  is  best  adapted  for  general  use,  as  it 
may  be  modified  and  even  combined  with  extension.  The  most  practical 
forms  are  those  described  by  Beely  and  Stimson.  (Figs.  110,  111,  112.) 
Splints  may  be  made  of  strips  of  wood  or  moulded  papier-mache  bound 
on  with  gauze  or  starch  bandages,  but  these  are  all  inferior  to  the 
moulded  plaster  splint.  Kramer's  wire  splints  are  often  useful  in  an 
emergency;  also  the  right-angled  tin-gutter  splints. 

Post-traumatic  swelling  demands  particular  care  in  fractures  about 
the  elbow-joint.  If  the  patient  is  not  under  constant  observation,  as, 
for  example,  in  a  hospital,  the  dressing  should  be  inspected  at  least 
during  the  first  twenty-four  hours  to  prevent  circulatory  disturbance, 


174 


INJURIES  OF  THE  ELBOW-JOINT. 


especially  in  children.  The  parents  or  relatives  should  always  be  warned 
of  the  danger  of  constriction,  and  should  be  on  the  lookout  for  cyanosis 
and  coldness  in  the  fingers,  numbness,  or  severe  pain.  The  first  dressing 
should  not  be  left  on  as  a  rule  more  than  eight  days,  namely,  till  the 
swelling  has  subsided.  The  dressing  should  then  be  replaced  by  one 
fitting  more  snugly,  after  the  fragments  have  been  carefully  adjusted. 

All  splints  should  be  removed  not  later  than  the  third  week.     In  the 
case  of  children  they  may  often  be  removed  sooner.    The  arm  should 

Fig.  112. 


Stimson's  plaeter-of-Paris  splints. 


then  remain  free  or  be  bandaged  only  at  night.  Following  the  removal 
of  the  splint,  daily  massage,  warm  baths,  active  and  passive  motion 
should  be  instituted  in  order  to  overcome  at  the  earliest  moment  the 
resulting  stiffness  of  the  joints  and  fingers. 

For  the  elbow-joint  particularly  it  is  important  to  remove  the  splint 
at  the  earliest  possible  moment;  the  minimum  time  of  fixation,  as  empha- 
sized by  Kocher,  gives  the  best  results.  If  in  three  weeks  the  normal 
position  is  not  obtained,  fixation  is  of  no  further  avail. 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW  JOINT.     175 


Semiflexion  is  the  rule  in  fixation  for  fractures  of  the  elbow-joint  to 
obtain  the  best  union  as  well  as  to  avoid  the  compromising  effects  of 
ankylosis  in  the  position  of  extension.  The  uselessness  of  an  arm 
ankylosed  in  extension,  if  once  seen,  is  never  forgotten. 

The  value  of  the  semiflexed  position  for  fixation  of  supracondyloid 
fractures  is  demonstrated  beyond  question  by  the  x-ray.  Smith,  from  the 
results  of  his  experience,  recommends  fixation  in  sharp  flexion  in  order 
to  overcome  the  tendency  of  the  short  lower  fragment  to  tilt  backward. 

With  proper  coaptation  of  the  fragments  the  results  of  treatment  of 
supracondyloid  fractures  are  usually  good,  except  where  the  joint  is 
involved.  The  resulting  stiffness  in  the  joint  often  persists  for  months, 
especially  in  old  individuals,  in  spite  of  daily  exercise. 

The  results  are  very  different  if  the  displacement  is  not  corrected  or 
occurs  secondarily  in  the  splint.  The  persistence  of  a  deformity  such 
as  occurs  in  the  common  form  (Fig.  107)  may  produce  very  great  limi- 
tation of  motion.  If  flexed,  the  forearm  strikes  against  the  projecting 
upper  fragment  of  the  humerus.  Flexion  is  thus  impossible  beyond  a 
right  angle.  Extension  is  limited  by  the  tension  of  the  biceps  over  the 
projecting  edge  of  the  fragment  as  well  as  by  the  large  callus  resulting 
from  the  displacement.  The  importance  of  reducing  the  displacement 
can  therefore  hardly  be  overestimated. 

Fig.  113. 


Bardenheuer's  extension  apparatus  for  supracondyloid  fracture  of  humerus.     ( Griissner. ) 

Treatment  by  extension  has  been  recommended  especially  in  the  case 
of  children,  whose  round  short  arms  give  so  little  purchase  to  prevent 
displacement  within  the  splint.     (Fig.  113.) 

Various  viewrs  are  still  held  in  regard  to  the  proper  position  of  the 
forearm  in  an  extension  splint.  No  rule,  however,  is  possible.  The 
position  should  vary  with  the  requirements  of  the  individual  case.  After 
manipulation  and  traction  have  secured  the  best  coaptation,  particularly 
with  the  aid  of  the  a>ray,  Kocher  recommends  that  the  arm  should 
be  left  free,  and  emphasizes  further  that  it  is  important  that  the  lateral 


176 


INJURIES  OF  THE  ELBOW-JOIST. 


traction  upon  the  forearm  should  be  exerted  outward  and  upward  to 
prevent  lateral  displacement  of  the  arm  —  that  is,  ulnar  adduction — 
which  is  easily  produced  by  its  own  weight. 

The  advantage  of  extension  combined  with  the  recumbent  position  is 
the  possibility  of  obtaining  exact  coaptation  of  the  fragments.  (Fig.  114.) 
How  far  swelling  of  the  soft  parts,  oedema  about  the  joint,  and,  as  in- 
dicated by  Bardenheuer,  the  formation  of  callus,  are  influenced  favorably 
by  extension,  cannot  be  determined.  Production  of  bone  confined  to 
normal  limits  depends  apparently  upon  the  favorable  position  of  the 
fragments. 

The  form  of  extension  splint  mentioned  is  not  applicable  to  ambulant 
cases.  The  ambulant  treatment  of  fractures  of  the  elbow  should  be 
avoided,  if  possible,  especially  in  the  case  of  children  and  old  individuals, 


Fig.  114. 


Extension  treatment  of  supracondyloid  fracture. 


on  account  of  the  marked  swelling  in  the  dependent  arm  and  the  possi- 
bility of  inflammatory  oedema.  Bardenheuer's  method  of  applying  an 
adjustable  extension  splint  can  be  used  if  desired. 

In  the  less  common  form  of  so-called  flexion  fracture  the  dislocation 
is  usually  slight,  and  is  corrected  by  the  simple  plaster  splint. 

Prognosis. — The  prognosis  of  supracondyloid  fracture  with  the  proper 
treatment  is  favorable.  On  the  other  hand,  if  the  deformity  is  not 
corrected,  motion  mav  be  verv  greatlv  limited,  namelv,  to  20  or  30 
degrees. 

If  the  surgeon  has  to  deal  with  cases  of  stiffness  and  limited  motion 
resulting  from  improper  treatment,  passive  motion  should  be  first  tried. 
Correction  of  the  position,  however,  in  such  cases  is  usually  impossible, 
even  by  secondary  operation.     The  position  may  be  improved  by  a 


FRACTURES  OF  FSDS  OF  BOXES  FORM  I  St;   ELBOW  JOINT.     177 

wedge-shaped  excision,  but  the  disturbance  produced  by  the  upper  frag- 
ment projecting  against  the  elbow  will  be  overcome  with  difficulty. 
Partial  removal  of  the  projecting  edge  through  a  longitudinal  incision 
may  effect  slight  improvement. 

Supracondyloid  Fracture  of  the  Humerus  with  Longitudinal  Frac- 
ture between  the  Condyles  (T-  and  Y-shaped  Fractures).  -There  are 
many  varieties  of  this  form  of  fracture.  The  fracture-line  may  be  a 
combination  of  fracture  of  the  outer  and  inner  condyles,  or  of  the  supra- 
condyloid fracture  with  longitudinal  fracture,  T-  or  Y-shaped  between 
the  condyles.     (Figs.  115  and  116.) 

The  variableness  and  complex  form  of  the  fracture-lines  are  usually 
the  result  of  direct  violence.  These  fractures  occur  more  frequently  in 
adults  than  in  children  from  the  fact  that  external  violence,  such  as 
blows,  falls  from  a  great  height  upon  the  elbow,  contusion  and  street 
accidents,  is  the  determining  factor.  No  predisposition  is  necessary; 
the  external  violence  is  decisive. 


Fig.  115. 


T-fracture  of  the  lower  end  of  the  humerus. 


Y-fraeture  of  tne  condyles,     (v.  Bruns.) 


Etiology  and  Mechanism. — Yladelung,  from  experimental  studies,  con- 
cluded that  the  T-fracture  was  produced  by  external  violence  driving 
the  olecranon  like  a  wedge  into  the  humerus,  thereby  cleaving  the  lower 
end  of  the  humerus.  Experiments  made  by  Marcuse  disprove  this 
action,  as  he  produced  a  Y-shaped  fracture  by  a  blow  upon  the  lower 
end  of  the  humerus  even  after  resecting  the  olecranon.  Kocher  believes 
that  it  is  a  combination  of  two  fractures.  Violence  acting  upon  the  lower 
end  of  the  humerus,  as  will  be  seen  later,  is  more  liable  to  fracture 
the  external  condyle.  The  continuation  of  the  same  force  acting  upon 
the  internal  condyle  alone  breaks  the  latter  and  completes  this  form  of 
fracture.  The  possibility  cannot  be  excluded  of  a  wedge  action  of  the 
shaft  of  the  humerus  producing  the  cleavage  of  the  condyles.  (Gurlt.)  At 
any  rate,  it  almost  always  forces  acting  directly  upon  the  elbow-joint, 
Vol.  Ill— 12 


178  INJURIES  OF  THE  ELBOW- JOINT. 

or  a  fall  upon  the  elbow-joint  from  a  great  height,  that  immediately 
affects  the  lower  end  of  the  humerus,  which  give  rise  to  the  various  forms 
of  T-fracture.  The  fragments,  after  being  broken  off,  are  still  further 
displaced  by  the  force,  so  that  the  humerus  is  driven  between  the  frag- 
ments and  increases  the  separation. 

Symptoms. — The  T-fracture  has  several  symptoms  in  common  with 
supracondyloid  fracture.  The  swelling,  pain,  and  loss  of  function  in  the 
joint  are  more  pronounced,  however,  as  the  fracture-line  involves  the 
joint.  The  surgeon  notes  the  amount  of  swelling  and  the  position  of 
the  arm,  points  of  tenderness  on  pressure,  and  the  pain  produced  by 
abduction,  adduction,  flexion  and  extension,  and  jarring.  Under  an 
anaesthetic  accurate  palpation  and  motion  will  usually  demonstrate 
crepitus,  and  in  contrast  to  the  marked  loss  of  function  observed  in 
active  motion  as  a  result  of  the  pain,  abnormal  mobility,  especially 
adduction  and  abduction,  as  well  as  the  possibility  of  hyperextension, 
are  evident. 

From  these  symptoms  alone,  however,  the  only  possibility  would  be 
supracondyloid  fracture.  In  order  further  to  determine  the  fracture-line 
between  the  condyles,  it  is  necessary  to  ascertain  the  intermobility  of 
the  latter.  Seizing  the  epicondyles  between  the  thumb  and  first  finger 
it  is  often  possible  to  move  the  condyles  upon  each  other.  If  the  con- 
dyles are  separated,  they  will  converge  under  pressure.  Palpation  will 
demonstrate  the  abnormal  width  of  the  cubital  process.  Pressing  the 
condyles  together  also  elicits  pain,  a  symptom  absent  in  supracondyloid 
fracture. 

Diagnosis. — Jn  spite  of  the  complexity  of  the  fracture-line  and  the 
frequent  multiplicity  of  the  fragments  a  methodical  examination  will 
eventually  permit  of  an  exact  diagnosis. 

As  T-  and  Y-shaped  fractures  are  usually  produced  only  by  marked 
violence,  backward  or  forward  displacement  of  the  upper  end  of  the 
humerus  and  a  resulting  cubitus  valgus  or  varus  are  not  infrequent. 

Treatment. — Treatment  aims  to  overcome  the  displacement  and  reduce 
the  fragments  to  their  normal  relation  by  pressure.  In  severe  fractures 
an  exact  reposition  of  the  joint-surfaces  is  important,  a  task  that  is  often 
not  easy  to  accomplish.  In  these  cases  the  .r-ray  is  an  indispensable  aid 
during  the  manipulation.  The  reduction  should  be  done  under  anaes- 
thesia. 

One  great  difficulty  in  the  treatment  is  to  hold  the  various  fragments 
in  their  proper  position.  The  importance  of  exact  coaptation  of  the 
fragments  for  the  function  of  the  joint  and  of  prevention  of  compromis- 
ing callus  for  the  prognosis  is  self-evident. 

Many  views  are  still  held  in  regard  to  the  treatment  of  T-fractures. 
The  simplest  and  most  practical  methods  are  here,  as  in  the  case  of 
supracondyloid  fractures,  fixation  by  means  of  a  plaster  strip  or  circular 
splint,  etc.  For  fractures  with  marked  displacement  of  the  fragments,  it 
is  a  good  plan  to  apply  a  circular  splint  for  about  ten  or  fourteen  days. 
During  its  application  the  fragments  maybe  held  in  position  by  traction 
by  means  of  flannel  strips  incorporated  in  the  dressing.    At  the  end  of 


i. 

c 

< 


< 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     179 

fourteen  days  a  two-strip  plaster  splint  may  be  applied  and  removed 
at  intervals  for  massage  and  gentle  passive  motion.  All  fixation  splints 
should  be  left  off  of  the  elbow-joint  after  the  third  week.  Recently 
extension  splints  have  met  with  more  general  use.  Their  advantage  is 
unquestionable,  but  in  very  serious  fractures  of  the  joint  they  do  not 
prevent  the  unfortunate  results  of  joint-stiffness.  Their  superiority, 
however,  is  cited  by  many  authorities,  among  them  Konig,  Kocher, 
Stimson,  and  others. 

Lauenstein  has  recently  indicated  the  advantage  of  extension  with 
the  arm  extended  instead  of  flexed,  to  prevent  union  with  abnormal 
adduction  or  abduction  of  the  forearm.  The  possibility  of  the  joint 
becoming  ankylosed  in  extension  demands  the  removal  of  the  splint  at 
the  end  of  eight  or  ten  days,  and  gradual  flexion  of  the  forearm  to  a 
position  of  semiflexion  or  acute  flexion.  This  circumstance  therefore 
makes  the  method  objectionable  except  for  very  severe  cases. 

The  application  of  the  extension  splint  with  the  arm  in  semiflexion  is 
done  in  the  same  manner  as  for  supracondyloid  fractures.  (See  Fig.  114.) 

As  a  rule  neither  the  extension  nor  the  common  plaster  splint  should 
be  left  on  longer  than  three  weeks.  At  the  end  of  this  time  the  existence 
or  the  possibility  of  joint-stiffness  requires  massage,  baths,  and  passive 
motion  in  order  to  break  up  the  adhesions,  prevent  further  shrinkage 
of  the  ligaments  and  capsule,  and,  if  possible,  to  check  and  smooth  off 
any  callus  formation. 

The  fact  that  the  intra-articular  fracture-lines  of  T-  or  Y-shaped  frac- 
tures of  the  humerus  make  the  prognosis  much  less  favorable  than  in  the 
case  of  the  simple  supracondyloid  type  has  been  provocation  for  the 
attempt  to  improve  the  chances  of  recovery  by  operative  interference. 

Kocher  has  published  the  results  of  his  numerous  attempts  in  this 
direction.  Resection  of  the  two  fractured  condyles  produced  an 
unfavorable  result  in  leaving  a  flabby  and  relatively  powerless  joint. 
On  this  account  he  attempted  later,  in  cases  of  isolated  fracture  of 
the  external  condyle,  to  avoid  any  essential  injury  by  limiting  resection 
to  the  external  condyle.  In  this  manner  growth  of  callus  in  the  joint 
is  most  easily  prevented  and  healing  simplified  to  a  certain  extent.  The 
solidity  and  mobility  of  the  joint  are  not  altered,  as  the  trochlea  suffices 
for  flexion  and  extension,  and  pronation  and  supination  are  effected  in 
the  joint  between  the  radius  and  ulna.  The  external  condyle  is  reached 
through  an  external  longitudinal  incision,  and  is  removed  without  diffi- 
culty; at  the  same  time  the  position  of  the  other  fragments  is  determined. 

Such  interference  is  certainly  justified  by  the  generally  unfavorable 
prognosis  of  T-fractures.  In  the  larger  number  of  cases,  however,  the 
question  of  operation  arises  usually  at  a  late  period,  after  massage  and 
exercise  have  failed  to  overcome  severe  and  persistent  loss  of  function. 

The  nature  of  the  operation  will  be  determined  in  each  case  by  the 
nature  of  the  functional  disturbance  and  of  the  fracture-lines.  Callus 
formations  situated  in  the  fossa  supratrochlearis  posterior  and  prevent- 
ing full  extension,  or  in  the  fossa  supratrochlearis  anterior  compromising 
flexion,  may  be  chiselled  off  with  good  results.     Malposition  of  the 


180  INJURIES  OF  THE  ELBOW- JOINT. 

external  or  internal  condyle  with  deviation  of  the  forearm  in  abduction 
or  adduction  may  be  corrected  finally  by  wedge-shaped  resection  of  the 
shaft  of  the  humerus. 

The  operative  treatment  of  complete  ankylosis  of  the  elbow-joint 
following  fractures  is  a  difficult  question.  Total  resection  always  presents 
the  possibility  of  a  flabby  joint,  and  the  latter  is  generally  less  useful  to 
the  patient  than  one  that  is  ankylosed. 

The  technic  of  complete  resection  is  described  in  the  section  on  Resec- 
tion of  the  Elbow-joint.  Recently,  Wolff  recommended  the  so-called 
operation  of  arthrolysis — separation,  chiselling  away,  and  removal  of 
all  bony  or  fibrous  bands,  bridges,  or  deposits  without  resection  of  the 
entire  articular  surface — and  testifies  to  the  good  results.  Eiselsberg 
opened  the  ankylosed  joint  through  two  lateral  incisions  and  obtained 
partial  restoration  of  the  mobility.  The  procedure  is  the  same  as  that 
which  he  employed  for  reposition  of  old  dislocations.  (See  under  Dis- 
location of  the  Forearm.) 

T-  and  Y-fracture. — No  fractures  of  the  elbow-joint  are  complicated 
by  injuries  of  the  soft  parts  so  frequently  as  T-  and  Y-fractures.  As  a 
result  of  the  severe  external  violence  which  is  the  common  cause  of  these 
fractures,  the  most  diverse  lesions  of  the  skin  and  soft  parts  occur,  in 
part  as  a  direct  result  of  the  trauma,  partly  from  perforation  of  the 
fracture  ends,  usually  the  upper  one,  through  the  soft  parts,  either 
behind  through  the  triceps  or  more  frequently  in  front  through  the 
biceps,  or  at  the  inner  or  outer  side  of  the  arm. 

In  the  perforating  fractures  the  danger  of  complications,  especially 
of  inflammation  and  suppuration,  is  not  as  great  as  in  severe  comminuted 
fractures  produced  by  direct  external  violence,  and  accompanied  often 
with  extensive  contusion  and  laceration  of  the  soft  parts. 

Treatment. — The  treatment  of  fracture  with  perforation  of  the  skin 
by  the  ends  of  the  fragments  consists  in  careful  disinfection  of  the  skin- 
wound  and  excision  of  its  edges.  If  the  skin,  soft  parts,  and  projecting 
bone  are  soiled,  the  unclean  pieces  of  bone  should  be  removed  and  the 
wound  cleaned  up  thoroughly  by  excision  of  all  damaged  fascia  and 
muscle.  Irrigation  with  antiseptic  solutions  is  not  as  effectual  as  the 
careful  removal  with  scalpel  and  scissors  of  all  soiled  parts.  The  fracture 
ends  are  replaced  only  after  thorough  cleansing  and  if  necessary,  resec- 
tion. The  importance  of  free  drainage  of  such  wounds  is  self-evident. 
In  the  event  of  inflammation  extending  to  the  elbow-joint,  the  same 
must  be  opened  and  drained  either  through  the  wound  or  through  a 
counteropening  on  the  posterior  surface  at  the  side  of  the  olecranon. 
The  most  important  subcutaneous  injuries  of  the  soft  parts  resulting 
not  infrequently  from  T-  or  comminuted  fractures  are  the  lesions  of 
the  nerves  and  the  cubital  artery.  Injury  of  the  cubital  artery  and 
the  median  nerve  lying  to  the  inner  side  of  the  artery  is  frequently 
observed  as  a  result  of  the  usual  dislocation  forward  of  the  upper  frag- 
ment of  the  humerus.  Regarding  the  details  of  the  disturbances  result- 
ing from  injury  to  the  nerve  and  vessel,  the  reader  is  referred  to  the 
section  on  Injuries  of  the  Soft  Parts  of  the  Elbow. 


FRACTURES  OF  ENDS  OF  BONES  FORMING   ELBOW-JOINT.     181 

Fracture  of  the  External  Condyle  of  the  Hunerus.— Fracture  or 
avulsion  of  the  external  condyle  is  relatively  frequent. 

Mechanism  and  Cause. — The  mechanism  and  the  cause  may  vary 
greatly.  A  force  acting  upon  the  lower  end  of  the  humerus  and  upon 
the  externa]  condyle  alone  may  fracture  the  latter.  Usually  the  break 
results  from  a  fall  upon  the  hand  with  the  arm  extended  or  slightly 
flexed,  or  by  a  fall  upon  the  elbow  itself.  By  falling  upon  the  hand 
the  force  is  transmitted  chiefly  through  the  radius  to  the  adjacent  external 
condyle  and  eminentia  capitata,  thereby  pressing  off  the  condyle.  It 
may  also  he  broken  off,  as  Kocher  demonstrated,  by  a  blow  upon  the 
olecranon  in  falling  upon  the  abducted  arm,  the  olecranon  being  driven 
against  the  outer  condyle.  A  direct  blow  against  the  lower  articular 
surface  of  the  humerus  may  result  also  in  separation  of  the  external 
condyle  alone,  according  to  Kocher's  experiments,  for  the  reason  that 
the  external  condyle  breaks  more  easily  than  the  internal. 


Fig.  117. 


Fig.  118. 


Lines  of  fracture  of  the  external 
condyle.     (Stimson.) 


Fracture  of  the  external  condyle.     (Child  a^ed 
5  years. ) 


Corresponding  to  these  differences  in  the  mechanism  the  fracture-line 
is  variable,  even  though  slightly  so.  A  small  part  of  the  trochlea  is 
often  broken  off  with  the  eminentia  capitata.  The  fracture-line  extends 
upward  above  the  external  epicondyle.  The  fracture  occurs  most  fre- 
quently in  children.  Fig.  118  shows  an  a>ray  picture  of  such  a  fracture 
in  a  child  of  five  years.  The  capitulum  humeri,  in  which  the  primary 
centre  is  developing,  is  broken  off  with  a  piece  of  the  lower  end  of  the 
shaft.  Between  these  two  displaced  shadows  lies  the  normal  line  of  the 
epiphysis. 

Symptoms. — The  deformity  of  fracture  of  the  external  condyle  may 
be  very  slight  in  the  absence  of  displacement.  Motion  in  the  joint  is 
often  only  slightly  disturbed,  so  that  only  extreme  flexion  and  extension 


182  INJURIES  OF  THE  ELBOW-JOINT. 

are  painful.  The  involvement  of  the  elbow-joint  is  denoted  only  by  swell- 
ing in  the  region  of  the  outer  condyle  and  by  intra-articular  hemorrhage. 
By  direct  palpation  of  the  elbow  one  obtains  pain  by  compressing  the  con- 
dyle, mobility  of  the  outer  condyle,  and  occasionally  crepitus.  An  impor- 
tant symptom  for  the  differential  diagnosis  is  demonstrated  by  abducting 
and  adducting  the  extended  arm.  By  the  tearing  off  of  the  outer  condyle 
the  radius  is  no  longer  held  by  the  external  lateral  ligament  (ligamentum 
collaterale  radiale),  so  that  the  forearm  can  be  abnormally  adducted. 
Normally  with  respect  to  the  upper  arm  the  forearm  is  in  a  position  of 
slight  cubitus  valgus.  By  avulsion  of  the  external  condyle  the  fixation 
effected  by  the  external  ligament  is  lost.  The  radius,  external  lateral  liga- 
ment (ligamentum  collaterale),  and  condyle  being  no  longer  held  in 
position,  the  forearm  can  be  adducted  to  a  cubitus  varus  position.  Press- 
ing the  forearm  against  the  humerus  in  abduction  is  especially  painful, 
as  the  head  of  the  radius  is  thus  pushed  against  the  displaced  condyle. 
This  tenderness  is  absent  if  the  extended  forearm  is  pressed  against 
the  upper  arm  in  adduction  or  the  normal  position. 

Diagnosis. — Accurate  determination  of  the  relative  position  of  the 
external  and  internal  condyles  and  olecranon  may  not  aid  the  diagnosis 
if,  as  is  common,  no  displacement  of  the  fragment  exists.  It  is  impor- 
tant to  remember  that  the  position  of  the  external  epicondyle  usually 
indicates  the  position  of  the  condyle,  as  isolated  avulsion  of  the  epicon- 
dyle is  extremely  rare  and  occurs  almost  entirely  in  connection  with 
posterior  dislocation  of  the  forearm. 

Cases  are  occasionally  seen  with  a  typical  displacement  of  the  fractured 
condyle,  usually  backward,  as  indicated  by  Mouchet;  rarely  forward. 
It  is  natural  that  under  these  circumstances  the  increased  distance 
between  the  external  epicondyle  and  the  olecranon  should  denote 
displacement  and  fracture;  the  relations,  however,  may  be  much  more 
complicated,  as  the  ulna  may  be  dislocated  at  the  same  time  and  the 
olecranon  lie  in  the  cleft  between  the  fragment  and  the  trochlea.  The 
distance  of  the  olecranon  from  the  inner  condyle  would  then  be 
increased.  If  such  a  luxation  or  subluxation  complicates  the  avulsion 
of  the  condyle,  it  is  evidenced  not  only  by  the  marked  loss  of  function, 
but  also  by  the  changed  relation  of  all  fixed  points. 

Uncomplicated  fracture  of  the  external  condyle  with  backward  dis- 
placement of  the  fragment  is  shown  by  tenderness  on  pressure,  crepitus, 
and  false  motion  in  the  sense  of  a  cubitus  varus.  In  certain  cases  it  is 
possible,  in  the  absence  of  any  great  swelling,  to  feel  the  sharp  edge  of 
the  dislocated  fragment  posteriorly  close  to  the  olecranon.  In  this  posi- 
tion it  may  be  mistaken  for  the  head  of  the  radius  on  superficial  exami- 
nation, and  so  the  condition  is  mistaken  for  backward  dislocation  of  the 
radius.    (Mouchet.) 

Prognosis. — Involvement  of  the  joint  makes  the  prognosis  of  fracture 
of  the  external  condyle  unfavorable,  as  the  fracture  lies  partly  within 
the  joint,  and  callus  production  and  adhesions  may  cause  permanent 
impairment  of  motion.  For  this  reason  it  is  important  to  begin  passive 
motion  as  soon  as  possible — that  is,  at  the  end  of  the  second  week,  other- 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     183 

wise  the  limitation  of  motion  is  overcome  with  increasing  difficulty.    The 

case  shown  in  the  .r-rav  picture  (Fig'.  118)  recovered  with  full  motion. 

Treatment.  —  For  the  average  case  with  slight  displacement  the  plaster 
splints,  plaster  strips  or  other  strip  splints  applied  for  between  two  and 
three  weeks  with  the  joint  semiflexed  will  give  good  results.  To  prevent 
displacement  of  the  fragment,  the  hand  can  be  pronated  strongly.  The 
most  rational  treatment,  however,  is  extension  with  the  arm  outstretched 
to  prevent  the  possibility  of  cubitus  varus.  The  extension  apparatus  is 
easily  attached  to  any  bed;  a  board  is  laid  in  sideways,  a  pulley  attached 
at  its  outer  end,  and  the  weight  and  traction  cords  adjusted  over  it.  The 
arm  may  be  placed  upon  an  inclined  pillow;  no  traveller  is  necessary. 

Reduction  is  often  difficult.  Operation  may  be  necessary  both  to 
determine  the  conditions  present  and  to  replace  and  suture  the  fragment 
in  its  normal  position.  Kocher,  among  others,  has  resorted  to  this  pro- 
cedure in  many  cases,  and  has  found  the  fragment  rotated  in  one  case 
through  ISO  degrees,  the  fracture-surface  facing  outward.  Beck  has 
made  the  same  observation.  Mouchet  found  the  fragment  had  rotated 
through  00  degrees  in  4  different  cases. 

Incision  and  exposure  of  the  joint  are  not  difficult,  as  the  posterior 
surface  of  the  external  condyle  is  readily  accessible,  and  the  radial  nerve 
is  easily  retracted  and  protected.  If,  upon  incising  and  exposing  the 
joint,  suture  of  the  fragment  presents  any  great  difficulty,  Kocher  advises 
its  removal.  His  experience  shows  that  such  a  resection  does  not  essen- 
tially disturb  the  function  of  the  joint,  and  may  be  therefore  employed 
without  hesitation.  Further,  the  removal  of  the  condyle  materially  im- 
proves the  chances  for  recovery,  as  the  formation  of  callus  is  not  so  liable 
to  encroach  upon  the  joint.  Kocher  cites  the  good  functional  results 
of  this  operation,  and  recommends  resection  of  the  external  condyle 
secondarily  for  the  cases  of  fracture  of  the  external  condyle  followed  by 
severe  loss  of  function. 

The  question  of  operative  interference  usually  arises  after  recovery 
in  the  cases  in  which  expectant  treatment — namely,  failure  to  reduce 
displacement  of  the  fragment — has  produced  marked  functional  disturb- 
ance. At  the  present  time  there  is  no  doubt  that  the  relatively  slight 
danger  of  such  operations  upon  the  joints  and  the  possibility  of  obtaining 
accurate  information  with  the  .r-rav  of  the  conditions  present  will  lead 
to  greater  developments  in  this  field. 

Exuberant  callus  production  about  the  dislocated  fragment  may  in- 
crease to  the  dimensions  of  an  exostosis  on  the  posterior  surface  of  the 
joint,  as  noted  by  Mouchet,  and  greatly  limit  motion. 

Fracture  of  the  External  Epicondyle. — Fracture  of  the  external  epi- 
condyle is  relatively  infrequent  and  needs  only  brief  mention.  It  occurs 
almost  exclusively  from  direct  violence  acting  upon  the  outer  side  of  the 
lower  end  of  the  humerus  and  chipping  off  small  pieces  of  the  epicondyle. 
The  fracture  is  frequently  complicated  by  lesions  of  the  skin.  Under 
these  circumstances  the  diagnosis  is  not  difficult.  In  simple  fracture,  in 
favorable  cases,  the  mobility  of  the  epicondyle  and  localized  swelling  and 
tenderness  are  recognizable.  Exceptionally  slight  passive  ulnar  adduction 


184 


INJURIES  OF  THE  ELBOW-JOINT. 


of  the  forearm  is  possible.  Slight  tears  and  avulsion  of  the  external  epi- 
condyle  as  well  as  of  the  internal  epicondyle  often  accompany  backward 
dislocation  of  the  forearm. 

In  children  fractures  of  the  epicondyles  are  essentially  epiphyseal 
separation,  as  the  epiphyseal  line  of  the  external  epicondyle  begins  to 
ossify  at  about  the  fifteenth  year.  The  so-called  "tear-fracture"  accom- 
panying luxation  is  almost  without  exception  a  separation  in  the  epi- 
physeal line. 

Treatment. — In  the  simple  form,  in  which  the  fracture-line  is  extra- 
articular, rest  for  about  eight  to  fourteen  days  is  sufficient  to  overcome  the 
pain,  sensitiveness,  and  swelling.     There  is  usually  no  loss  of  function. 

Fig.  119  represents  a  tear-fracture  of  both  epicondyles  in  a  thirteen- 
year-old  boy.  The  fracture  on  both  sides  is  recognizable  as  a  separation 
in  the  epiphyseal  line.     In  the  external  condyle  several  small  primary 


Fig.  119. 


Fig.   120. 


Fracture  of  the  external  and  internal  epicon- 
dyles.     Boy  aged  13  years. 


Fracture  of  the  external  epicondyle. 
iGurlt.  i 


centres  are  visible.  The  primary  centres  appear  in  the  external  con- 
dyle at  about  the  ninth  year.  In  the  fourteenth  or  fifteenth  year  the 
epiphyseal  line  is  calcified.  In  this  case  the  tear-fractures  resulted  from 
hyperextension  of  the  elbow-joint  in  falling  upon  the  hand,  producing 
posterior  dislocation  of  the  forearm.  The  fragments, sensitive  to  pressure, 
could  be  moved  about  beneath  the  skin.  Union  followed  without  loss  of 
function. 

Fracture  of  the  Internal  Epicondyle. — Fracture  of  the  internal  epi- 
condyle is  of  frequent  observation,  especially  in  youth.  As  the  epiphyseal 
line  exists  until  the  fifteenth  or  sixteenth  year,  the  injury  frequently  occurs 
as  a  separation  of  the  epiphysis  up  to  this  age. 

From  its  exposed  position  the  internal  epicondyle  is  subjected  to 
direct  violence,  as  a  fall  upon  the  abducted  arm,  or  a  blow;  more  fre- 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     185 

quently,  however,  the  break  occurs  as  a  tear-fracture.  The  internal 
epicondyle  is  the  point  of  insertion  of  the  strong  internal  lateral  ligament. 
Sudden  movements,  subjecting  the  ligament  to  abnormal  tension,  usually 
tear  the  epicondyle,  but  not  the  ligament.  Such  tears,  affecting  the  in- 
ternal ligament,  result  from  abduction  of  the  forearm  as  well  as  from 
hyperextension.  By  a  fall  upon  the  outstretched  arm  hyperextension 
is  often  the  cause  of  posterior  dislocation  of  the  forearm,  and,  as  is  easily 
understood,  the  cause  of  avulsion  of  the  inner  epicondyle.  Fracture  of 
the  inner  epicondyle  may  he  at  times  mistaken  for  a  posterior  dislocation. 
For  many  reasons  tear-fracture  of  the  inner  epicondyle  may  be  regarded 
as  an  injury  predisposing  to  luxation.  In  all  of  the  author's  cases  of 
posterior  dislocation  of  the  forearm  during  the  tenth  to  the  fifteenth 
years,  the  period  of  greatest  frequency,  the  internal  epicondyle  was  torn 
off.  It  is  justifiable,  therefore,  to  claim  an  etiological  relation  between 
luxation  and  separation  of  the  epicondyle  in  the  epiphyseal  line  in  this 
period.  The  fracture  is  associated  almost  constantly  with  lateral  dis- 
location, especially  outward,  of  the  forearm. 

Knowledge  of  the  production  of  the  fracture  by  hyperextension  is 
important  to  understand  the  not  infrequent  intra-articular  hemorrhage 
accompanying  tear-fractures  of  this  epicondyle.  The  explanation  is 
that  simultaneous  with  the  fracture  the  anterior  part  of  the  capsule  is 
torn  by  the  hyperextension,  thus  giving  the  symptoms  of  an  extra- 
articular fracture  combined  with  an  apparent  intra-articular  lesion.  The 
intra-articular  hemorrhage  may  result  exceptionally  from  a  joint-fracture, 
as  fracture  of  the  epicondyle  is  frequently  combined  withT-  and  Y-shaped 
fractures  and  the  so-called  diacondyloid  fractures.  Such  joint-fractures 
are  excluded  or  confirmed  by  testing  the  mobility.  In  simple  avulsion 
of  the  epicondyle  joint-motion  is  complete.  Crepitus  of  the  fragment  is 
usually  obtainable. 

By  the  traction  of  the  ligament  the  fragment  is  usually  displaced  down- 
ward. The  fragment  may  be  concealed  by  circumscribed  extravasation 
or  be  palpable  at  times  in  the  region  of  the  ulnar  nerve  which  it  covers. 
The  fracture  is  evidenced,  in  addition  to  the  local  extravasation,  by 
slight  abnormal  mobility — radial  abduction — of  the  forearm. 

Fracture  of  the  epicondyle  by  direct  violence  may  be  accompanied 
by  injury  of  the  ulnar  nerve,  shown  by  numbness  or  paralysis  in  the 
area  supplied.    These  paralyses  usually  recover  quickly. 

Xo  splint  is  able  to  hold  the  fragment  in  its  normal  place  if  it  is 
dislocated  downward.  During  recovery  attention  should  be  directed  to 
preventing  joint-stiffness.  At  the  end  of  eight  to  ten  days  active  and 
passive  motion  is  advisable.  Treatment  by  extension  with  the  arm 
outstretched,  which,  according  to  Bardenheuer,  is  supposed  to  effect 
fixation  of  the  fragment  in  its  normal  position,  appears  illusory,  as  with 
the  forearm  extended  the  internal  lateral  ligament  is  not  relaxed. 

In  all  cases  with  marked  displacement  the  question  of  operation  must 
be  considered.  The  fragment  may  be  sutured  in  place  with  catgut,  as  it 
is  usually  in  part  cartilaginous.  If  fixation  is  difficult,  the  fragment  may 
be  excised  and  the  ligament  sutured  in  place. 


186 


INJURIES  OF  THE  ELBOW-JOIST. 


Excision  is  indicated  further,  as  noted  by  Koeher,  for  cases  in  which 
joint-motion  is  interfered  with  by  malunion — for  example,  if  the  frag- 
ment lies  so  near  the  joint  as  to  prevent  flexion  and  extension.  The 
incision  is  made  to  the  inner  side  of  the  olecranon  and  the  ulnar  nerve 
retracted.     It  may  not  be  necessary  to  open  the  joint. 

Fracture  of  the  Inner  Condyle. — The  reason  of  the  relative  infre- 
quency  of  this  injury  as  compared  with  fracture  of  the  external  condyle 
has  not  been  satisfactorily  explained.  The  cause  is  usually  a  direct  blow 
or  fall  upon  the  inner  surface  of  the  elbow.  The  diagnosis  is  made 
usually  only  by  careful  examination  of  the  swelling,  tenderness,  and 
abnormal  passive  mobility  of  the  forearm  in  the  sense  of  abduction  and 
hyperextension.  If  the  fragment  is  displaced,  abnormal  mobility  may 
be  obtained  by  direct  palpation.     Fig.  122  is  from  a  woman  sixty-four 


Fig.  121. 


Fig.   122. 


Upper  and  lower  limits  of  fracture  of  the 
internal  condyle.     (Stimson. 


Fracture  of  the  internal  condyle.     Woman 
ajjred  61. 


vears  old,  who  fell  while  carrying  a  package  under  the  arm  and  struck 
upon  the  posterior  surface  of  the  forearm.  The  blow  upon  the  ulna  and 
the  olecranon  drove  the  latter  against  the  condyle.  After  fourteen  days 
of  fixation  in  a  plaster-strip  splint  motion  was  begun,  which  on  account 
of  the  age  of  the  patient  was  possible  only  to  GO  degrees.  Complete 
reposition  of  the  displaced  fragment  was  impossible.  (Fig.  123.)  Gurlt 
reports  several  cases  of  fracture  of  the  inner  condyle  in  which  the  ulna, 
remaining  in  contact  with  the  fragment,  was  dislocated  backward.  The 
radius  may  thus  be  dislocated  partially  or  completely  and  project  back- 
ward so  that  the  joint-surface  of  the  head  is  palpable.  Id  those  frac- 
tures combined  with  dislocation,  the  easy  reducibility  of  an  apparently 
superficial  luxation  points  to  a  complication  and  demands  an  accurate 
determination  of  the  fixed  bony  points. 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     187 

Prognosis. — Little  is  known  of  the  prognosis  of  the  fracture  on  accounl 
of  its  rarity. 

Treatment. — Kocher  recommends  ;i  plaster  splint  for  two  or  three 
weeks  or  continuous  extension.  Reduction  is  best  accomplished  by 
traction  upon  the  upper  end  of  the  Hexed  forearm  in  the  axis  of  the 
upper  arm.  Motion  should  be  begun  in  two  weeks  ;it  the  latest  in  order 
to  prevent  or  overcome  adhesions  in  the  joints. 

Diacondyloid  Fracture;  Separation  in  the  Epiphyseal  Line.  By 
this  term  is  meant  fracture  or  avulsion  of  the  articular  process  alone. 
The  fracture-line  lies  below  the  epicondyles;  usually  the  surgeon  is 
dealing  with  a  separation  of  the  epiphysis.  (Fig.  124.)  It  occurs  most 
commonly  in  childhood  up  to  the  fifteenth  year. 


Fig.   123 


Fig.   124. 


Fracture  of  the  internal  eondvle. 


Line  of  the  lower  epiphysis. 


According  to  Kocher \s  experiments,  the  fracture  is  produced  by  a 
direct  blow  against  the  elbow  in  the  axis  of  the  humerus.  The  condyloid 
process  is  tints  broken  off.  The  normal  curve  of  the  cubital  process 
favors  this  form  of  injury.  In  childhood  the  process  may  be  torn  off 
during  hyperextension  by  the  pressure  of  the  tense  anterior  part  of  the 
capsule. 

The  fracture,  if  purely  intra-articular,  is  difficult  to  diagnosticate. 
The  swelling  of  the  joint,  the  tenderness,  and  the  marked  loss  of  active 
motion  indicate  a  severe  intra-articular  lesion.  False  motion  is  possible; 
with  the  epicondyles  fixed,  the  forearm  may  be  pushed  outward,  inward, 
and  even  backward  and  forward.  The  backward  displacement  may  be 
such  as  to  resemble  posterior  dislocation  of  the  elbow.  Occasionally 
the  edge  of  the  fragment  may  be  felt  at  either  side  of  the  olecranon 


188 


INJURIES  OF  THE  ELBOW-JOINT. 


behind.  The  extension  method  with  the  arm  outstretched  gives  the  best 
fixation,  the  tension  of  the  capsule  holding  the  fragment  in  its  normal 
position.  In  children  fixation  with  the  arm  extended  should  not  be 
continued  longer  than  ten  to  fourteen  days.  Afterward  the  tendency  to 
stiffness  should  be  overcome  by  gradual  flexion. 

Fig.  125  shows  a  separation  of  the  epiphysis  in  a  child  of  four  years. 
The  primary  centre  in  the  capitulum  is  displaced  inward  with  the  bones 
of  the  forearm  against  the  lower  end  of  the  humerus.  The  causation  in 
this  case  was  not  stated. 


Fig.  125. 


Fig.  126. 


Diacondyloid  fracture  of  the  humerus  with 
inward  displacement.  Separation  in  the 
epiphyseal  line.     Child  aged  four  years. 


Fracture  of  the  capitulum  humeri  with  forward 
dislocation. 


Fracture  of  the  Capitulum  of  the  Humerus  (Eminentia  Capitata). — 
This  form  of  fracture,  not  uncommon  according  to  Kocher,  is  scarcely 
mentioned  in  the  text-books.  The  lesion  consists  in  a  peeling  off  of  the 
capitulum.  It  is  observed  usually  in  the  second  decade,  and  is  caused 
by  the  same  forces  which  produce  fracture  of  the  external  condyle — 
that  is,  a  fall  upon  the  hand;  also  pressure  of  the  tense  capsule  against 
the  eminentia  is  supposed  to  push  off  the  cartilaginous  covering  like  a 
cap. 

Symptoms. — The  symptoms  of  the  fracture  are  fairly  characteristic, 
although  the  loss  of  function  and  pain  are  not  so  marked  as  to  point 
immediately  to  a  fracture.  On  superficial  examination  the  break  may 
be  overlooked.  The  arm  is  held  fixed  in  incomplete  extension.  Passive 
motion  may  be  possible  to  almost  complete  extension.  Sometimes  the 
resistance  felt  during  extension  gives  way  suddenly  and  motion  becomes 
entirely  free.  This  happens  probably  from  the  slipping  back  of  the 
fragment  into  place.    Supination  is  usually  impaired  and  painful. 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     189 

Careful  inspection  of  the  joint  after  the  swelling  has  subsided  reveals 
a  prominence  near  the  head  of  the  radius.  On  palpation  it  may  have 
the  peculiarities  of  a  floating  cartilage.  In  extension  the  sharp  edge  of 
the  fragment  is  easily  palpable  below  the  external  epicondyle;  the  frag- 
ment may  possibly  he  pushed  into  the  joint-cavity  or  with  certain  move- 
ments slip  in  spontaneously. 

Diagnosis. — Alternating  freedom  and  loss  of  motion  should  make  the 
surgeon  think  of  this  form  of  fracture.  If  a  fragment  is  demonstrable, 
it  can  be  confused  only  with  a  fracture  of  the  head  of  the  radius;  the 
latter  is  excluded  by  palpation  of  the  head  of  the  radius  in  pronation 
and  supination.  In  one  case  seen  flexion  and  extension  were  greatly 
limited  and  painful,  also  pronation  and  supination.  Symptoms  attrib- 
utable to  wedging  of  the  fragment  were  not  present. 

Treatment. — The  diagnosis  being  established,  immediate  removal  of 
the  fragment  by  operation  is  advisable,  and  is  accomplished  without 
difficulty  through  an  incision  on  the  outer  side  of  the  joint  after  incising 
the  capsule.  The  results  of  such  interference  are  very  favorable.  Pro- 
longed fixation  with  splints  is  unnecessary. 

For  a  critical  analysis  of  a'-ray  pictures  of  fractures  at  the  lower  end 
of  the  humerus  during  the  age  of  development,  a  knowledge  of  the 
normal  epiphyseal  growth  is  necessary.  In  the  second  year  a  primary 
centre  appears  in  the  capitulum  (Figs.  118  and  125);  in  the  tenth  or 
eleventh  year  in  the  trochlea.  (Fig.  136.)  The  primary  centre  in  the 
trochlea,  from  its  serrated  outline,  may  be  easily  mistaken  for  a  splinter. 
The  epiphyseal  line  ossifies  in  the  seventeenth  or  eighteenth  year.  In 
case  of  doubt  it  is  best  to  compare  radiographs  of  both  elbows. 

Fractures  of  the  Upper  Ends  of  the  Bones  of  the  Forearm. 

The  fact  that  the  head  of  the  radius  and  the  incisura  semilunaris  of 
the  ulna  are  enclosed  within  the  capsule  of  the  elbow-joint  stamps  all 
fractures  of  the  bones  of  the  forearm  occurring  within  this  region  as 
intra-articular.  For  this  reason  it  seems  best  to  describe  them  following 
fractures  of  the  lower  end  of  the  humerus.  Of  the  fractures  of  the  upper 
end  of  the  radius,  those  to  be  considered  are  fracture  of  the  head  and  the 
rare  fracture  of  the  neck;  of  fractures  of  the  ulna,  the  relatively  frequent 
fracture  of  the  olecranon  and  avulsion  fracture  of  the  coronoid  process. 

Fracture  of  the  Coronoid  Process  of  the  Ulna. — This  fracture  is 
rare,  and  is  usually  associated  with  backward  or  lateral  dislocation  of 
both  bones  of  the  forearm.  A  dislocation  that  is  easily  reducible  points 
to  the  existence  of  this  fracture. 

According  to  Lotzbeck,  the  fracture  results  from  a  fall  upon  the  ulnar 
border  of  the  hand  with  the  arm  somewhat  flexed.  The  blow  is  trans- 
mitted to  the  ulna  and  thence  to  the  coronoid  process,  which  is  broken 
off  by  the  counterpressure  of  the  trochlea.  A  few  cases  are  reported 
of  supposedly  pure  tear-fractures  resulting  from  contraction  of  the 
brachialis. 


190  INJURIES  OF  THE  ELBOW-JOINT. 

The  fracture-line  lies  near  the  tip  of  the  process,  and  at  the  base  it  is 
extremely  rare;  the  author  has  seen  it  in  1  case  accompanying  outward 
dislocation  of  the  forearm.  As  the  coronoid  process  is  partly  covered 
by  the  strong  fibrous  attachments  of  the  lateral  ligaments,  and  further 
by  the  annular  ligament,  which  is  in  turn  strengthened  by  the  tendon  of 
the  brachialis,  any  marked  displacement  of  the  fragment  is  impossible. 

Symptoms. — On  account  of  the  deep  and  covered  position  of  the 
process  the  fracture  may  be  almost  without  symptoms.  Urlichs  describes 
them  briefly  as  follows:  If  a  patient  who  has  fallen  upon  the  hand 
complains  of  pain  localized  in  the  plica  cubiti;  if  swelling  exists  and 
the  articular  surfaces  and  fixed  points  are  in  their  normal  position  and 
indicate  no  change;  if  movement,  active  and  passive,  is  impaired;  and 
finally,  if  a  somewhat  doubtful  friction-sound  can  be  elicited  at  the  site 
of  the  coronoid  process,  the  surgeon  is  justified  in  diagnosticating  a 
fracture  limited  to  the  process.  Occasionally  pain  produced  by  forced 
flexion  is  characteristic,  the  process  being  pressed  against  the  anterior 
fossa. 

Prognosis. — The  usually  slight  displacement  of  the  small  fragment  is 
followed  as  a  rule  by  bony  or  fibrous  union;  the  prognosis  is  therefore 
favorable. 

Treatment. — The  treatment  is  simply  rest  and  fixation  for  eight  to 
ten  days  with  the  arm  semiflexed. 

Fracture  of  the  Olecranon. — Fractures  of  the  olecranon  are  relatively 
frequent,  and  result  from  direct  violence  on  account  of  the  exposed 
position  of  the  bone.  A  blow  or  fall  upon  the  olecranon  with  the  arm 
semiflexed  may  produce  a  direct  fracture.  If  the  periosteum  and  the 
tendinous  fibres  of  the  triceps  insertion  remain  intact,  the  fragments 
remain  in  contact  so  that  the  fracture-line  may  not  be  palpable  and  the 
fissure  recognizable  only  with  the  finger-nail.  As  a  rule,  however,  the 
upper  small  or  large  fragment  is  drawn  upward  by  the  triceps  and  the 
separation  of  the  fragments  easily  recognizable.  Direct  violence  often 
produces  splintering  of  the  upper  fragment. 

Less  frequently  the  fracture  may  occur  from  sudden  contraction  of 
the  triceps,  as  in  the  act  of  throwing;  also  from  hvperextension,  as  by 
a  fall  upon  the  hand.  The  olecranon  is  jammed  against  the  posterior 
supratrochlear  fossa  and  the  tip  chipped  off.  According  to  Oberst,  in 
fractures  resulting  from  muscular  traction,  only  a  shell  of  the  corticalis 
is  broken  off,  the  fractures  therefore  being  extra-articular  in  contrast  to 
those  produced  by  direct  violence.  The  middle  of  the  process  is  the 
common  seat  of  fracture;  fractures  of  the  base  have  been  observed  not 
infrequently  by  Oberst  and  by  the  author. 

Fracture  of  the  olecranon  may  be  combined  with  forward  dislocation 
of  the  forearm. 

Symptoms. — With  complete  separation  the  symptoms  of  fracture  of 
the  olecranon  are  unmistakable.  The  patient  allows  the  arm  to  hang 
at  the  side  and  supports  it  with  the  other  hand.  Flexion  is  possible  but 
painful ;  extension  is  impossible.  The  action  of  gravity  upon  the  forearm 
may  simulate  the  act  of  extension  if  the  arm  is  allowed  to  drop  from 


PLATE    IV 


FIG.    1. 


Old  Oblique  Fracture  of  Humerus,  with  Reversal  and  Overriding. 

Good  Union.     (Sollev.) 


Fracture  of  Olecranon,  Man  Aged  Forty-eight  Years.     (Solley.) 


FRACTURES  OF  ENDS  OF  HONES  FOUMINO    KL  BOW- JOINT.     \\)\ 

its  iionii.il  position  with  the  hand  supinated.  To  avoid  error,  extension 
should  be  attempted  againsl  resistance,  or,  better  still,  by  having  the 
patient  extend  the  arm  against  the  lone  of  gravity,  namely,  by  having  the 
patient  bend  over  until  the  posterior  surface  of  the  upper  arm  faces 

I  ']<;.   127. 


Fracture  of  the  olecranon,  fibrous  union.     (Malgaigne.) 

upward.  If  the  olecranon  is  fractured,  the  forearm  cannot  he  lifted  to 
a  horizontal  position.  On  palpation  the  cleft  of  the  fracture  line  is  easily 
felt.  The  presence  of  ecchymosis,  swelling,  and  intra-articular  hemor- 
rhage is  significant.     Crepitus  may  be  sometimes  obtained  by  rubbing 


Fig.   128. 


Fig.  129. 


Development  of  the  primary  centre  in  the  epiph- 
ysis of  the  olecranon  (thirteenth  year). 


Normal  epiphyseal  line  of  the  olecranon 
partially  ossified  (eighteenth  year). 


the  upper  fragment  against  the  lower.  If  separation  is  prevented  by  the 
integrity  of  the  periosteum  and  tendons,  extension  of  the  arm  may  be 
possible,  but  with  less  force  than  in  the  other  arm  and  accompanied  with 
pain;  even  in  this  case  accurate  palpation  will  demonstrate  a  fracture. 


192  INJURIES  OF  THE  ELBOW-JOINT. 

As  shown  by  x-ray  pictures,  there  is  a  marked  similarity  in  the  size 
and  displacement  of  the  fragments  in  the  average  case.  Fig.  130  shows 
the  usual  form  of  this  fracture  with  separation. 

In  regard  to  x-ray  pictures  of  fractures  of  the  olecranon,  the  conditions 
of  ossification  of  the  epiphysis  must  be  understood  to  avoid  the  deception 
otherwise  inevitable  in  young  subjects.  One,  occasionally  two,  primary 
centres  appear  in  the  epiphysis  of  the  olecranon  in  the  tenth  to  the 
twelfth  year.  Complete  ossification  of  the  epiphyseal  line  occurs  between 
the  seventeenth  and  nineteenth  years.  Fig.  128  shows  the  outline  of 
the  primary  centre  in  the  thirteenth  year;  Fig.  120  the  appearance  during 
ossification  of  the  epiphyseal  line.  The  latter  is  easily  mistaken  for 
fracture,  and  the  former  has  been  regarded  as  a  fracture  in  several 
instances  and  described  and  reproduced  as  such  recently.  Cases  of  pure 
epiphyseal  separation  of  the  olecranon  occur,  as  demonstrated  by  a  case 
of  v.  Brans. 

Prognosis. — The  prognosis  in  cases  without  displacement  is  favorable; 
in  those  with  marked  separation  of  the  fragments  bony  union  is  impos- 

Fig.  130. 


Old  fracture  of  the  olecranon  with  separation,  fibrous  union,  and  good  junction. 

sible  without  further  treatment.  Bony  union,  however,  is  not  absolutely 
essential  to  good  function.  Fig.  130  is  an  x-ray  picture  of  a  fracture 
recovering  without  impairment  of  power  or  motion.  The  remaining 
portion  of  the  olecranon  grew  in  the  course  of  time,  so  that  the  olecranon 
finally  regained  its  normal  size.  Interposition  of  parts  of  the  capsule 
or  tendons  may  prevent  bony  union. 

Treatment. — The  important  task  is  to  obtain  union  of  the  fracture- 
surfaces,  and  many  plans  are  proposed  for  this  purpose.  Lauenstein 
recommends  puncture  of  the  joint  to  remove  the  intra-articular  hemor- 
rhage which  tends  to  increase  the  separation.  This  is  advisable  only 
in  cases  of  very  profuse  intra-articular  hemorrhage,  as  the  extravasation 
is  usually  absorbed,  if  aided  by  rest  and  light  compression,  in  the  course 
of  eight  days.     For  apposition  of  the  fragments  fixation  with  the  arm 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     193 

extended  in  either  a  plaster  or  plaster-strip  splint  suffices  for  the  average 
case.  In  using  such  a  splint,  to  hold  the  upper  fragment  in  position  after 
drawing  it  down  forcibly,  a  figure-of-8  adhesive  plaster  bandage  may- 
he  applied  firmly  into  the  notch  above  the  olecranon,  crossing  in  front 
of  t  he  ell x >\v.  The  same  effect  may  be  obtained  by  means  of  a  long  strip  of 
plaster  reaching  from  above  the  olecranon  to  the  forearm  [combined  with 
a  circular  strip  fitting  into  the  groove  above  the  olecranon].  The  arm 
should  not  remain  in  the  splint  longer  than  ten  days.  At  the  end  of 
that  time  the  author  always  flexes  the  arm  gradually  to  avoid  stiffness; 
in  the  fourth  week  massage  and  passive  motion,  naturally  avoiding 
forced  flexion  at  the  outset. 

Sachs  has  recently  abandoned  all  fixation,  advising  massage  from  the 
beginning,  and  reporting  a  number  of  good  results  from  such  treatment. 

Fig.  131. 


A' 

Laminated  fracture  of  the  olecranon  :  a,  upper  fragment;  b,  external  condyle.     (Stimson.) 

The  author  doubts  whether  this  method  will  meet  with  general  accept- 
ance. The  results  obtained  by  Sachs  can  be  explained  equally  well  by 
the  fact  that  fractures  of  the  olecranon  recover  with  good  function  in 
spite  of  marked  diastasis. 

The  most  rational  treatment,  although  usually  unnecessary,  is  suture 
of  the  bones.  This  may  be  done  at  once,  or,  as  in  the  case  of  the  patella, 
in  a  few  days  after  absorption  of  the  extravasation.  Through  the  incision 
— preferably  a  flap-section  to  prevent  contact  of  the  skin  and  bone 
sutures — the  interposed  parts  of  the  capsule  are  excised  and  the  bone- 
surfaces  smoothed  off  if  necessary.  The  fragments  are  drilled  and 
sutured  with  thin  wire  [preferably  chromicized  catgut].  Konig  recom- 
mends fixation  of  the  joint  in  semiflexion  for  fourteen  days  after  sutur- 
ing, fixation  in  extension  being  inadvisable  on  account  of  the  difficulty 
and  painfulness  of  the  first  attempts  at  flexion. 

Suture  of  the  bones  may  be  done  secondarily  to  overcome  the  unsatis- 
factory results  of  other  treatment.  It  is  also  applicable  to  those  compound 
fractures  in  which  the  condition  of  the  wound  gives  a  fair  promise  of  an 
aseptic  course.  As  the  fracture  usually  results  from  direct  violence,  it 
Vol.  III.— 13 


194 


INJURIES  OF  THE  ELBOW-JOIST. 


is  compounded  with  great  frequency.  Compound  fractures  in  which 
the  danger  of  infection  is  great,  should  be  fixed  in  semiflexion  in  antici- 
pation of  ankylosis. 

Fracture  of  the  Head  of  the  Radius. — This  is  a  pure  intraarticular 
fracture.  A  frequently  observed  form  is  the  so-called  chisel-fracture,  a 
segment  being  broken  off  obliquely  from  the  head,  as  in  the  accom- 
panying illustration.     (Fig.   132.)     The  fragment   may  be  completely 

separated  or  merely  fissured.  If  the  fragment  is  free, 
it  may  act  as  a  corpus  mobile  in  the  joint.  As  a  rule 
it  is  held  by  periosteum. 

Etiology. — The  cause  is  indirect  violence,  espe- 
cially a  fall  upon  the  hand  with  the  forearm  mod- 
erately flexed  and  pronated.  The  anterior  part  of 
the  head  which  lies  in  contact  with  the  humerus  is 
thus  driven  against  the  articular  surface  of  the  latter 
and  the  margin  of  the  disk-shaped  articular  surface 
is  knocked  off.  v.  Bruns  first  called  attention  to  the 
relative  frequency  and  typical  form  of  the  fracture 
in  1880.  If  in  falling  upon  the  hand  the  arm  is 
more  abducted,  the  outer  side  of  the  head  receives 
the  chief  pressure  and  a  segment  of  the  outer  cir- 
cumference will  be  broken  off. 

Symptoms. — The  symptoms  may  be  concealed  by 
intra-artieular  hemorrhage.  On  palpation  pain  in 
the  region  of  the  head  denotes  an  injury  of  the 
and  extension,  pronation  and  supination  may  be 
on  the  other  hand,  during  rotation  a  broadening  of 
the  head  may  be  recognizable,  but,  as  emphasized  by  Malgaigne,  may 
be  mistaken  for  dislocation  of  the  head.  Crepitus,  which  may  be  noticed 
even  by  the  patient,  and  the  slight  movement  of  the  fragment  during 
pronation  and  supination  are  diagnostic.  Frequently  the  fragment  and 
its  mobility  may  be  felt,  as  well  as  the  line  of  cleavage.  As  already  seen, 
a  fall  upon  the  hand  is  an  etiological  factor  in  many  other  forms  of 
injury.  It  is  therefore  natural  that  the  <lii-el-fracture  of  the  capitulum 
radii  should  be  associated  occasionally  with  other  lesions,  such  as  avul- 
sion of  the  external  condyle  and  backward  dislocation  of  the  forearm. 
In  one  case  of  chisel-fracture  produced  by  a  fall  upon  the  hand,  motion 
was  limited  at  the  outset  to  70  or  80  degrees,  and  pronation  and  supina- 
tion were  markedly  impaired. 

By  reason  of  its  proximity,  the  radial  nerve,  whose  deep  branch 
courses  over  the  head  of  the  radius,  is  often  damaged  by  direct  injury. 
Motor  disturbances  of    the  hand  and  fingers  follow. 

Treatment.  —  Union  occurs  usually  without  severe  disturbances  if  the 
displacement  of  the  fragment  is  slight.  Exuberant  callus  formation  may 
compromise  pronation  and  supination;  for  this  reason,  if  the  disturbance 
is  marked,  resection  of  the  head  is  necessary.  If  small  splinters,  as 
sometimes  happens,  produce  secondary  disturbances  in  the  joint  by  their 
presence  as  free  bodies,  their  removal  by  operation  is  indicated. 


Fracture  <>f  tin-  head  <>t 
the  radius,      v.  Bruns. 


latter.      Flexion 
slightly  impairei 


II! A'  TUBES  OF  ENDS  OF  BOXES  FOBMING  ELBOW  JOINT.     195 

Fixation  for  two  weeks  in  any  of  the  ordinary  splints  suffices  for  this 
fracture.  It  is  better,  however,  to  remove  the  splint  frequently  and 
carry  oul  moderate  movements.  In  immobilizing,  the  arm  should  be 
semiflexed,  the  hand  semipronated,  and  the  latter  position  maintained 
by  carrying  the  strips  to  the  fingers. 

In  addition  to  the  usual  chisel-fracture,  fissures  and  incomplete  frac- 
tures have  been  seen,  usually  accompanying  dislocations;  also  in  con- 
nection with  fractures  of  the  external  condyle  and  capitulum  humeri,  and 
fractures  of  the  ulna  and  shaft  of  the  radius. 

Epiphyseal  separation  of  the  radial  head  is  little  known — in  fact,  very 
rare.  The  diagnosis  can  he  made  only  with  probability  from  the  local 
appearances,  which  are  similar  to  those  of  the  following  fractures.  A 
primary  centre  appears  in  the  head  of  the  radius  in  the  fifth  or  sixth 
year;  the  epiphyseal  line  ossifies  in  the  seventeenth  or  eighteenth  vear. 

Fracture  of  the  Neck  of  the  Radius, — This  fracture  is  rare,  and 
results  from  direct  violence,  also  indirect,  presumably  from  forced 
pronation.  In  regard  to  the  etiology  and  mechanism,  accurate  observa- 
tion and  investigation  are  lacking.  The  fracture  is  supposed  to  occur 
in  combination  with  backward  dislocation  of  the  ulna  and  with  fracture 
of  the  coronoid  process.  In  a  case  observed  by  Oberst  it  accompanied 
posterior  dislocation  of  the  forearm,  and  resulted  from  a  blow  upon  the 
elbow  received  in  a  fall  from  a  bicycle. 

Symptoms  and  Diagnosis. — The  symptoms  are  obtained  only  by  care- 
ful examination  of  the  head  of  the  radius  demonstrating  its  separation 
from  the  shaft  by  its  failure  to  accompany  the  movements  of  the  latter 
in  pronation  and  supination.  The  diagnosis  is  aided  by  local  tenderness, 
swelling,  and  crepitus.  Rotation  is  painful  and  limited.  The  fracture- 
ends  may  be  displaced. 

Treatment. — Fixation  should  be  in  semiflexion  to  prevent  displacement 
of  the  shaft  by  the  contraction  of  the  biceps. 

Subluxation  of  the  Radius. — Under  the  name  "derangement  interne" 
is  presented  a  symptom-complex  frequently  observed  in  children  and 
resulting  from  violent  traction  upon  the  forearm.  After  such  an  injury 
the  child  allows  the  forearm  to  hang  relaxed  as  if  paralyzed.  Usuall) 
no  injury  is  demonstrable  at  the  joint. 

As  to  the  nature  of  the  joint-disturbance,  opinion  is  divided  whether 
it  may  be  a  constriction  of  the  capsule  or  subluxation  of  the  radius. 
Streubel's  experiments  speak  for  the  latter  view.  He  demonstrated  on 
the  young  cadaver  that  by  forced  pronation  and  extension  of  the  forearm 
the  ligaments  and  capsule  could  be  stretched  in  such  a  manner  as  to  pro- 
duce a  gap  between  the  radius  and  eminentia  capitata  into  which  the 
capsule  could  enter.  If  the  forearm  was  not  pronated  this  condition 
persisted.  On  extending  and  supinating  the  arm,  however,  the  normal 
relations  are  restored.  The  same  condition  could  be  produced  by  supi- 
nation. Hultkrantz,  in  studying  the  anatomy  and  mechanism  of  the 
elbow-joint,  notes  that  in  young  children  the  demarcation  between  the 
capitulum  radii  and  shaft  is  less  pronounced,  and  the  entire  capsule — 


196  INJURIES  OF  THE  ELBOW-JOINT. 

that  is,  the  annular  ligament — is  weaker  and  more  yielding,  so  that  on 
the  cadaver  a  partial  dislocation  of  the  radius  could  easily  be  produced 
by  rotary  movements. 

The  question  deserves  further  investigation,  particularly  with  the  aid 
of  the  .r-ray. 

In  the  presence  of  the  above-mentioned  peculiar  symptom-complex 
in  children  attempts  at  supination  of  the  forearm  are  painful.  The  dis- 
turbance is  overcome  by  supination  of  and  traction  upon  the  arm  fol- 
lowed bv  flexion,  after  which  the  child  is  able  to  use  the  arm  again 
immediately. 

Complicated  Fractures  of  the  Elbow-joint. — Marked  violence,  ma- 
chinery injuries,  street  accidents,  etc.,  often  cause  simultaneous  fracture 
of  the  lower  end  of  the  humerus  and  of  the  bones  of  the  forearm.  Such 
fractures  are  usually  complicated  by  lesions  of  the  skin  and  soft  parts. 
The  same  principles  apply  to  their  treatment  as  in  compound  fractures, 
especially  those  of  the  joints. 

Based  upon  the  results  of  modern  asepsis  and  antisepsis  one  can 
recommend  for  such  cases  a  fairly  comprehensive  conservative  surgery. 
The  soft  parts  are  to  be  cleaned,  all  loose  splinters  of  bone  removed, 
and  the  site  of  fracture  covered  immediately  if  possible  with  a  skin- 
flap.  According  to  the  subsequent  course  will  arise  the  question  of 
amputation  of  the  humerus  or  resection  of  the  elbow-joint.  In  the  event 
of  injury  of  the  large  vessels  or  extensive  destruction  of  the  skin  accom- 
panying severe  compound  or  splinter-fractures,  amputation  of  the 
humerus  may  be  necessary,  especially  in  old  individuals,  in  whom  infec- 
tion of  the  bone  and  of  the  joint  is  always  more  dangerous  than  in  young 
and  healthy  subjects. 

Gunshot-fractures  of  the  elbow-joint  require  brief  mention.  Aside 
from  the  vast  statistics  of  such  injuries  in  war,  cases  of  this  sort  are 
rare.  It  is  not  the  purpose  of  a  text-book  of  practical  surgery  to  discuss 
the  earlier  methods  of  treatment  of  complicated  gunshot-fractures  of 
the  elbow-joint  and  their  results,  as  the  treatment  was  carried  out  partly 
tinder  unfavorable  circumstances. 

The  bone  lesions  produced  at  close  range  by  the  modern  small-calibre 
bullets  and  their  explosive  action  are  much  more  extensive  than  those 
observed  in  earlier  wars,  as  has  been  verified  by  accurate  experiments. 
In  such  cases  with  extensive  laceration  of  the  soft  parts  it  is  certain 
that  conservative  treatment  will  be  less  applicable  than  in  previous 
wars,  and  amputation  of  the  humerus  will  be  with  greater  frequency 
the  only  possible  treatment.  On  the  other  hand,  the  small-calibre 
bullet  at  long  range,  according  to  the  experience  of  recent  wars, 
produces  a  much  more  favorable  injury  in  the  bone  as  well  as  in 
the  soft  parts  than  the  large-calibre  bullets  without  metal  covering 
previously  did. 

Among  interesting  gunshot  injuries  should  be  mentioned  the  severe 
lesions  related  by  v.  Bruns  as  produced  by  the  English  Dum-dum 
bullets — small-calibre,  lead-tipped  bullets — and  by  the  new  hollow-point 
bullet.     The  accompanying  photograph  and  x-ray  picture  (Figs.  133  and 


FRACTURES  OF  ENDS  OF  BONES  FORMING  ELBOW-JOINT.     197 

134)  show  the  enormous  damage  to  the  soft   parts  and  the  complete 
destruction  of  the  ends  of  the  bones  produced  by  these  bullets. 

The  results  of  the  treatment  of  gunshot  injuries  of  the  elbow-joint 
in  late  wars  interest  surgeons  in  only  one  respect,  namely,  in  regard  to 
the   results  of  conservative  treatment   and   of  resection  of  the  elbow. 

Fig.  133. 


Gunshot  wound  of  the  elbow-joint  marie  by  a  lead-pointed  Duni-dum  bullet  at  close  range. 
(v.  Bruns'  experiments,  i 


According  to  the  statistics  of  Dominik,  among  163  cases  of  gunshot 
injuries  of  the  elbow-joint,  in  133  (81.6  per  cent.)  ankylosis  occurred; 
while  in  only  10  cases  (6  per  cent.)  was  free  motion  preserved.  Resection , 
on  the  other  hand,  gave  good  results,  presumably  in  52.8  per  cent.  These 
results  should  certainly  be  significant  for  the  question  of  treatment  of 
complicated  gunshot-fractures,  even  in  war.  All  operative  measures 
are  limited  in  war,  however,  on  account  of  the  unfavorable  conditions, 


198 


INJURIES  OF  THE  ELBOW-JOINT. 


to  the  very  urgent  cases,  so,  in  spite  of  the  above  statistics,  conservative 
treatment  will  still  be  the  rule  in  the  future  for  all  slight  and  moderate 
gunshot  injuries,  even  where  ankylosis  is  threatened. 


Fig    134. 


X-ray  of  Fig.  133. 


DISLOCATIONS  OF  THE  ELBOW. 


An  accurate  knowledge  of  the  normal  anatomy  of  the  elbow-joint  is 
as  essential  for  the  diagnosis  and  treatment  of  dislocations  as  for  the 
diagnosis  and  treatment  of  fractures.  The  determination  of  the  fixed 
bony  points,  the  relation  of  the  capsule  and  the  ligaments  are  mentioned 
in  the  introduction  to  the  treatment  of  fractures.  The  mechanism  of 
the  joint  is  described  at  the  same  place. 

As  the  elbow-joint  consists  of  the  articulation  of  three  different  bones, 
the  forms  of  dislocation  are  naturally  manifold.  Both  bones  of  the  fore- 
arm and  each  bone  individually  may  be  dislocated  in  various  directions. 


DISLOCATTO.XS  OF  THE  ELBOW. 


199 


Dislocations  of  the  elbow-joinl  arc  relatively  frequent.  They  occur 
more  commonly  in  children  and  young  subjects.  Women  and  children 
are  affected  more  frequently  than  men.  Petersen  gives  as  the  cause  in 
women  and  children  a  normally  existent  possibility  of  hyperextension, 
which  would  mean  a  certain  predisposition  to  this  injury. 

Surgeons  distinguish : 

Dislocation  of  both  bones  of  the  forearm: 

1.  Backward. 

2.  Lateral. 
'.].    Forward. 
4.  Divergent. 

Dislocation  of  one  bone  of  the  forearm: 

1.  Dislocations  of  the  ulna. 

2.  Dislocations  of  the  radius:  (a)  backward,   (b)   outward,  (c) 

forward. 

Dislocation  of  Both  Bones  of  the  Forearm. 

Backward  Dislocation. — This  frequent  form,  one  might  almost 
say  the  normal  form,  of  dislocation  of  the  elbow-joint  is  usually  pro- 
duced by  a  fall  upon  the  hand  with  the  arm  outstretched — that  is,  by 

Fig    135. 


Backward  dislocation  of  both  bones  of  the  forearm. 


hyperextension.  In  this  manner  the  forearm  is  hyperextended,  the  tip  of 
the  olecranon  is  jammed  against  the  fossa  supratrochlearis  posterior  and 
forms  a  fulcrum  over  which  the  lower  end  of  the  humerus  is  lifted  for- 
ward. The  anterior  portion  of  the  capsule  is  torn  from  the  resulting 
tension  and  the  lower  end  of  the  humerus  slips  through  the  rent.  The 
radius  and  ulna  slip  backward  and  the  coronoid  process  may  lie  upon 
the  trochlea  or  behind  it.    The  backward  dislocation  is  thus  completed. 


200  INJURIES  OF  THE  ELBOW-JOINT. 

The  .x-ray  picture  (Fig.  135)  shows  the  relation  of  the  ends  of  the  bones 
to  each  other. 

While  the  author  is  obliged  to  regard  the  above  mechanism  of  back- 
ward dislocation  of  the  forearm  as  the  usual  one,  the  dislocation  may 
occur  in  other  ways,  the  possibility  of  which  is  shown  to  him  more  by 
experiment  than  by  experience.  Schiiller  was  able  to  produce  the  dis- 
location by  a  heavy  blow  upon  the  posterior  surface  of  the  upper  arm, 
the  elbow-joint  being  flexed.  In  this  manner  the  joint-surface  of  the 
humerus  is  driven  forward. 

The  explanation  of  Schiiller,  also  founded  upon  experiments,  is  reason- 
able, namely,  that  by  forced  lateral  movements,  especially  radial  abduc- 
tion, dislocation  results  from  the  laceration  of  the  inner  lateral  ligament, 
the  bones  of  the  forearm,  especially  the  coronoid  process,  being  pushed 
backward  beneath  the  trochlea.  Taking  into  consideration  the  normally 
existent  radial  abduction,  cubitus  valgus,  which  is  especially  pronounced 
in  females,  such  an  abnormal  forced  abduction  by  falling  upon  the  hand 
with  the  arm  flexed  or  extended  seems  possible. 

The  degree  and  form  of  injury  of  the  joint,  capsule,  and  lateral  liga- 
ments vary  according  to  the  mechanism  of  origin. 

The  involvement  of  the  soft  parts  in  posterior  dislocation  of  the  fore- 
arm may  be  slight,  the  swelling  insignificant,  and  the  prominent  bony 
points  recognizable  on  inspection;  in  other  cases  the  lesions  of  the  soft 
parts  may  be  severe.  The  brachialis  anticus  may  be  torn  by  the  lower 
end  of  the  humerus,  and  exceptionally  the  median  nerve  and  the  cubital 
artery  may  be  damaged.  The  cubital  process  has  been  known  to  per- 
forate the  skin  in  front  of  the  joint. 

Diagnosis. — The  diagnosis  of  the  usual  form  of  posterior  dislocation 
of  the  forearm  is  not  difficult.  It  is  even  less  excusable  not  to  make 
the  diagnosis  at  once,  as  the  failure  to  do  so  is  more  serious  than  in 
the  case  of  fracture,  for  severe  functional  disturbance  always  persists 
if  reposition  is  not  timely  and  complete. 

On  inspection  the  arm  is  moderately  flexed,  between  140  and  150 
degrees;  the  patient  either  allows  the  arm  to  hang  or  supports  it  with 
the  other  hand.  If  the  patient  is  sitting,  the  arm  is  usually  supported 
upon  the  thigh.  In  the  absence  of  any  marked  swelling  the  tightened 
triceps  tendon  projects  like  a  cord  upon  the  posterior  surface,  the  contour 
of  the  latter  being  curved  backward.  To  the  outer  side  of  the  triceps 
tendon  is  a  deep  depression  in  which  the  sharp  outline  of  the  head  of 
the  radius  is  recognizable  beneath  the  stretched  skin.  On  palpation 
below  and  to  the  outer  side  of  the  olecranon  is  felt  the  disk-shaped 
articular  surface  of  the  head  of  the  radius,  further  identified  by  rotating. 
Above  the  olecranon  deep  pressure  must  be  made  in  the  depression  to 
touch  the  posterior  surface  of  the  humerus.  The  olecranon  lies  at  a 
greater  distance  from  the  epicondyles  than  in  the  other  arm  and  above 
the  line  drawn  between  them.  The  head  of  the  radius  lies  farther  behind 
and  below  the  external  epicondyle  than  normally.  On  the  anterior  sur- 
face of  the  joint  the  cubital  process  is  felt  as  a  prominence  pushing  the 
soft  parts  forward.    The  axis  of  the  upper  arm  meets  that  of  the  lower 


DISLOCATIONS  OF  THE  ELBOW.  201 

arm  anterior  to  the  point  of  intersection  on  the  normal  side.  Palpation 
may  be  greatly  hindered  by  much  swelling.  Most  important  is  the  test 
of  motion;  as  the  displacement  of  the  dislocated  part,  in  this  ease  the 
forearm,  results  from  violence,  and  the  arm  is  fixed  by  the  still  intact 
ligaments,  marked  limitation  of  motion  is  the  rule.  There  is  an  elastic 
resistance  to  motion,  unyielding  to  even  considerable  force.  This  fixation 
and  loss  of  active  and  passive  motion  are  differential  against  fracture, 
particularly  against  the  in  other  respects  not  dissimilar  supracondyloid 
fracture,  in  which,  as  related,  a  similar  deformity  is  produced  by  the 
backward  displacement  of  the  lower  fragment.  In  fracture,  however, 
the  fixed  points  are  not  altered. 

Prognosis. — If  the  diagnosis  and  treatment  are  immediate,  the  prog- 
nosis for  reduction  and  functional  restoration  is  usually  favorable.  If 
the  injury  is  recent  and  uncomplicated,  reduction  is  generally  simple 
and  easy.  At  the  end  of  three  or  four  weeks,  on  the  other  hand,  reduc- 
tion is  often  extremely  difficult  and  sometimes  impossible  in  spite  of  all 
manipulation.  This  does  not  imply  that  all  dislocations  are  irreducible 
at  the  end  of  this  time.  Cases  are  known  in  which  reduction  was  accom- 
plished in  the  usual  manner  at  the  end  of  several  months,  but  they  are 
exceptional.  As  a  rule  dislocations  remaining  unreduced  for  several 
weeks  require  operative  interference,  a  fact  which  shows  the  importance 
of  immediate  diagnosis  and  reposition. 

Treatment. — Reduction  is  best  accomplished  by  simple  traction  on 
the  forearm,  the  upper  arm  being  held  by  an  assistant.  The  author  has 
found  this  method  satisfactory  in  almost  every  case.  The  forearm  may 
be  rotated  and  flexed  and  extended  slightly  with  advantage  during  trac- 
tion. Konig  is  the  only  one  to  relate  this  form  of  reposition.  It  requires 
much  less  force  than  reduction  by  hyperextension.  Anaesthesia  is  advisa- 
ble in  all  methods,  although  reduction  by  simple  traction  is  often  effected 
without  it.  Many  other  methods  are  suggested,  among  them  the  so-called 
physiological  method  of  Roser,  which  attempts  reduction  in  the  reverse 
direction  of  origin.  The  forearm  is  hyperextended,  a  fulcrum  thus  being 
established  on  the  posterior  surface  of  the  upper  arm.  The  coronoid 
process  is  thus  lifted  off  and  freed.  By  traction  on  the  forearm  the  joint- 
surfaces  of  the  bones  of  the  forearm  are  drawn  forward  against  those  of 
the  cubital  process,  and  by  flexion  the  normal  position  is  restored.  The 
author  does  not  recommend  Roser's  method  for  the  first  or  for  general 
application.  Forcible  hyperextension  not  infrequently  causes  new  in- 
juries by  stretching  the  capsule  and  ligaments  on  the  anterior  surface. 
For  this  reason  the  physiological  method  is  inferior  to  every  manipula- 
tion which  accomplishes  reduction  more  simply  and  with  less  violence. 
The  old  method  of  forced  flexion  is  often  valuable.  The  arm,  flexed,  is 
laid  upon  the  forearm  of  the  operator,  the  latter  acting  as  a  lever,  and 
reposition  effected  by  traction  upon  the  forearm  with  direct  pressure 
upon  the  upper  end.  The  so-called  "  distraction  "  method  of  Dumreicher 
consists  in  exerting  downward  traction  upon  the  upper  part  of  the  fore- 
arm in  the  axis  of  the  humerus,  at  the  same  time  pulling  upon  the 
forearm  in  its  axis  as  it  is  brought  gradually  to  semiflexion. 


202  INJURIES  OF  THE  ELBOW-JOINT. 

The  above  methods  may  be  tried,  but  simple  traction  on  the  forearm 
is  sufficient  for  recent  cases  and  rarely  fails.  Reduction  accomplished, 
rest  is  enforced  for  eight  days  to  allow  of  resorption  of  the  swelling  and 
hemorrhage;  then  motion  is  begun  and  continued  until  it  is  entirely  free. 
The  surgeon  should  guard  against  secondary  shrinkage  and  the  resulting 
stiffness  of  the  joint  which  may  occur  at  a  late  period.  This  subsequent 
impairment  of  motion  may  depend  upon  lesions  of  the  capsule,  ligaments, 
or  bones  peculiar  to  this  form  of  dislocation.  As  this  applies  usually  to 
the  anterior  part  of  the  capsule  and  the  adjacent  ligaments,  the  elbow- 
joint  shows  a  tendency  to  become  flexed,  and  especially  limited  in  ex- 
tension. It  is  necessary  to  combat  forcibly  this  tendency  to  contractures 
by  passive  motion.  Mechanical  apparatus  or  manual  traction  and  ex- 
tension are  serviceable.  The  patient  may  often  obtain  complete  exten- 
sion of  the  arm  by  carrying  a  weight. 

Slight  lesions  of  the  bones  complicating  posterior  dislocation  may  make 
the  diagnosis  difficult.  Easy  reducibility  by  simple  traction  may  signify 
that  there  is  a  fracture  of  the  coronoid  process.  In  such  instances  the 
dislocation  is  as  readily  reproduced  by  a  blow.  As  mentioned,  posterior 
dislocation  occurs  with  striking  frequency  from  the  tenth  to  the  four- 
teenth year.  In  all  luxations  at  this  age  the  author  has  found  a  tear- 
fracture  of  the  internal  epicondyle  in  the  epiphyseal  line.  To  him  it 
appears  that  this  fracture  should  not  be  regarded  as  an  adventitious 
accompaniment  of  the  dislocation,  but  rather  that  this  fragility  of  the  epi- 
condyle at  the  epiphyseal  line  determines  the  surprising  frequency  of 
dislocation  up  to  the  age  at  which  the  epiphyseal  line  ossifies.  (See 
Fig.  119.)  Fracture  of  the  external  condyle  frequently  accompanies 
posterior  dislocation,  as  recent  away  examination  has  taught.  Crepitus 
may  be  distinct,  and  is  then  positive  evidence.  The  chipping  off  of  small 
fragments  can  often  be  only  surmised  unless  shown  by  the  a;- ray.  If 
small  fragments  occasion  considerable  loss  of  motion,  they  should  be 
removed.  In  individual  instances  their  removal  may  be  difficult.  In 
some  cases  simple  incision  is  sufficient;  in  others,  extensive  exposure 
of  the  joint  may  be  necessary.  For  the  details  of  the  operation  for  this 
purpose,  namely,  an  arthrotomy,  the  reader  is  referred  to  the  various 
sections  on  Arthrotomy,  Resection,  and  Reposition  of  Old  Irreducible 
Dislocations. 

Irreducible  Backward  Dislocation.— Backward  dislocation  of  the 
forearm  usually  becomes  irreducible  in  from  three  to  four  weeks,  if  for 
any  reason  reduction  does  not  immediately  follow  the  accident.  In  the 
interval  the  swelling  gradually  subsides  and  motion  is  somewhat  regained. 
The  shrinkage  and  cicatrization  of  the  capsule,  ligaments,  and  surround- 
ing soft  parts  fix  the  bones,  so  that  they  can  no  longer  be  restored  to 
their  normal  position.  Only  a  few  cases  are  known  in  which  after 
months  or  a  longer  period  reduction  was  possible.  Accordingly,  for  an 
old  unreduced  dislocation  there  is  no  choice  but  operative  interference. 
Where  a  fair  amount  of  motion  has  been  recovered,  as  happens  excep- 
tionally, reduction  may  not  be  absolutely  necessary. 


DISLOCATIONS  OF  THE  ELBOW.  203 

Various  operative  procedures  are  suggested  for  old  dislocations.  Tren- 
delenburg and  Volker  divide  the  olecranon  transversely  and  suture  it 
subsequently.    Trendelenburg  advises  a  flap  section  over  the  olecranon 

to  separate  the  sutures  of  the  hone  and  skin.  The  olecranon  is  cut  off 
carefully  with  a  broad  chisel,  the  ulnar  nerve  being  protected.  A  good 
view  of  the  joint  can  thus  be  obtained  and  the  radius  and  ulna  replaced. 
The  arm  is  then  extended  and  the  olecranon  drilled  and  sutured  with  wire. 
At  the  end  of  fourteen  days  the  arm  is  gradually  Hexed  and  mobilized. 
v.  Bruns  recommends  partial  resection  of  the  lower  end  of  the  humerus; 
both  by  reason  of  the  simplicity  of  the  procedure  and  its  results,  it  is 
preferable  to  partial  resection  of  the  radius  and  ulna  or  of  the  humerus 
and  the  head  of  the  radius,  or  of  the  end  of  the  humerus  and  the  ulna, 
or  complete  resection  of  the  elbow.  He  makes  two  lateral  incisions  to 
avoid  injuring  the  soft  parts.  The  separation  of  the  soft  parts  is  made 
difficult  by  adhesions  and  cicatrization.  The  periosteum  is  peeled  back 
and  the  bones  resected  with  a  Gigli  saw  or  with  the  ordinary  saw  after 
protruding  the  bone-ends  out  of  the  wound.  The  piece  resected  should 
not  be  too  small,  not  less  than  lh  to  2  inches  thick.  The  joint  may  be 
mobilized  at  the  end  of  the  third  week.  A  certain  amount  of  stiffness 
of  the  joint  is  desirable,  and  is  overcome  later  by  mechanical  exercises. 
After-treatment  is  necessary  for  several  weeks.  Resection  is  not  advis- 
able for  patients  under  fifteen  years,  as  the  removal  of  the  epiphyseal 
line  results  in  disturbances  of  growth  and  undesirable  shortening  of  the 
arm. 

The  method  of  v.  Eiselsberg  has  given  very  good  results,  and  is 
founded  upon  the  fact  that  the  irreducibility  of  old  dislocations  is  de- 
pendent upon  shrinkage  and  cicatrization  of  the  soft  parts.  He  opens 
the  joint  by  two  lateral  longitudinal  incisions.  All  growths,  cicatricial 
bands,  interposed  soft  parts,  and  fragments  of  bone  are  divided  or 
excised.  In  this  manner  the  ends  of  the  bones  are  cleaned  and  exposed 
to  within  h  mcri  °f  the  attachment  of  the  capsule.  Reposition  is  then 
possible  in  every  case.  Reduction  accomplished,  all  bands  preventing 
free  motion  are  divided  till  the  elbow-joint  is  free  in  all  its  movements. 
Several  times  it  was  necessary  to  resect  the  head  of  the  radius  where  a 
fracture  of  the  capitulum  prevented  proper  articulation  with  the  humerus. 
With  appropriate  after-treatment,  namely,  motion  at  the  end  of  three  to 
five  days,  and  passive  motion  continued  energetically  for  weeks,  v.  Eisels- 
berg's  results  were  very  satisfactory,  the  average  mobility  being  flexion 
to  60  degrees,  extension  to  160  degrees.  Certain lv  these  results  should 
encourage  more  general  employment  of  this  method,  as  it  is  essentially 
an  ideal  procedure  by  which  the  normal  joint  is  preserved  and  good 
function  obtained. 

Complications  may  occur  with  backward  dislocation  of  the  forearm 
in  the  nature  of  extensive  injuries  of  the  soft  parts  and  of  the  bones. 
The  median,  ulnar,  and  radial  nerves  may  be  torn  or  completely  severed, 
as  demonstrated  in  a  series  of  cases.  The  vessels  may  be  injured  and 
give  rise  to  large  hsematomata.  The  muscles  may  be  torn  extensively; 
the  end  of  the  humerus  may  perforate  the  skin  in  front.    These  injuries 


204  INJURIES  OF  THE  ELBOW- JOIST. 

demand  appropriate  aseptic  treatment,  excision  of  the  edges  of  the 
wound,  and  cleansing  of  the  cavity.  If  the  articular  surfaces  are  badly 
soiled  or  fractured,  partial  resection  may  be  necessary.  Inflammation 
and  suppuration  of  the  joint  demand  appropriate  drainage,  which,  if 
insufficient,  may  necessitate  further  incision  or  resection,  preferably  of 
the  lower  end  of  the  humerus. 

Lateral  Dislocation. — The  remaining  varieties  of  dislocation  require 
only  brief  mention,  as  some  are  very  rare,  while  others  present  no  difficulty 
in  diagnosis.  Lateral  dislocations  of  the  forearm  are  observed  most  fre- 
quently in  children.  Harm,  to  whom  surgeons  owe  the  first  comprehen- 
sive reports,  states  that  among  21  cases  18  were  in  children,  inward 
dislocation  being  the  more  common.  C.  Hiiter,  v.  Volkmann,  and  Spren- 
gel  observed  the  outward  variety  more  frequently.  The  dislocation  is 
usually  incomplete;  the  bones  of  the  forearm  are  displaced  either  so  far 
outward  that  the  joint-surface  of  the  ulna  touches  the  capitulum,  and 
the  head  of  the  radius,  lying  free,  pushes  the  soft  parts  outward  (Fig.  136) 
or  the  bones  of  the  forearm  may  be  displaced  inward,  the  head  of  the 
radius  touching  the  trochlea,  the  ulna  lying  more  or  less  free  at  the  inner, 
side  of  the  cubital  process. 

The  mechanism  of  these  forms  is  not  explained.  Violent  lateral 
pressure  combined  with  rotary  movement  may  be  the  cause;  outward 
dislocation  may  result  presumably  from  a  fall  upon  the  inner  side  of 
the  flexed  forearm.  Triquet  demonstrated  on  the  cadaver  that  inward 
dislocation  could  be  produced  by  forcible  pronation,  the  upper  arm  being 
fixed.  The  ligaments  and  capsule  can  be  severely  injured.  Frequently 
the  internal  lateral  ligament  is  torn  or  the  internal  epicondyle  torn 
off,  the  latter  injury  being  found  in  all  of  Hiiter's  five  specimens  from 
the  Langenbeck  clinic.  Fig.  136  is  a  characteristic  .r-ray  picture  of 
incomplete  outward  dislocation.  At  the  inner  side  of  the  ulna  lies  a 
round  piece  of  bone  recognizable  as  the  avulsed  inner  epicondyle.  The 
serrated  primary  centre  of  the  trochlea  lies  in  its  normal  position  above 
the  displaced  epicondyle.  The  defect  at  the  point  of  attachment  of  the 
epicondyle  is  not  shown  on  account  of  the  slight  rotation  of  the  humerus 
in  the  picture. 

Diagnosis. — Diagnosis  is  often  hindered  by  articular  swelling,  and  not 
infrequently  it  is  false  and  the  lesion  regarded  as  a  sprain.  Careful 
examination,  especially  under  anaesthesia,  will  demonstrate  the  bony 
points;  in  outward  dislocation  the  head  of  the  radius  is  very  prominent, 
projecting  beyond  the  external  condyle,  even  the  disk  being  palpable 
under  circumstances;  on  the  inner  side  part  of  the  trochlea  may  be  felt. 
In  inward  incomplete  dislocation  the  external  condyle  projects  abnor- 
mally; the  internal  condyle  is  covered  partly  or  entirely  by  the  olecranon. 
With  much  swelling  slight  deviations  of  the  axis  of  the  forearm  are  often 
not  easily  recognizable.  The  impairment  of  motion  may  vary  greatly, 
being  influenced  in  addition  by  complicating  fractures  of  the  external 
or  internal  epicondyle,  coronoid  process,  or  head  of  the  radius.  The 
determination  of  the  fixed  bony  points  shows  most  accurately  the  relative 
displacement  of  the  head  of  the  radius,  the  olecranon,  and  the  epicondyles. 


DISLOCATIONS  OF  THE  ELBOW. 


205 


Treatment. — The  prognosis  is  not  unfavorable.  Reposition  is  easily 
effected  in  recent  cases  by  simple  traction  on  the  forearm,  accompanied 
by  direct  pressure  upon  the  dislocated  bones,  and,  if  desired,  combined 
with  pronation  and  supination.  Failure  to  reduce  a  recent  dislocation 
is  due  to  interposition  of  the  capsule  or  fragments  of  hone,  and  calls  for 
operative  interference.  The  x-ray  is  indispensable  for  the  diagnosis  of 
hone  fragments.  The  after-treatment  consists  in  rest  from  eight  to  ten 
davs  in  a  splint  and  sling,  followed  by  passive  motion  for  several  weeks. 
An  old  unreduced  dislocation  requires  operation  to  prevent  ankylosis, 
possibly  resection  of  the  ends  of  one  or  more  bones,  usually  the  end  of 
the  humerus.     Reports  on  these  procedures  are  few. 


Fig.  136. 


Fig.  137. 


Incomplete  outward  dislocation  of  tli 

forearm.     Boy  aged  thirteen  years. 


Complete  outward  dislocation  of  the  forearm  with 
fracture  of  .  the  internal  epicondyle.  Man  aged 
twenty  years. 


The  so-called  complete  lateral  dislocation  is  rare.  The  upper  end  of 
the  radius  and  ulna  lie  at  the  side  of  the  cubital  process  of  the  humerus, 
so  that  the  joint  appears  doubled  in  width.  The  diagnosis  is  simple. 
In  complete  dislocation  outward  the  forearm  is  flexed  or  extended  in 
extreme  pronation,  and  generally  abducted — cubitus  valgus.  (Fig.  137.) 
The  ends  of  the  bones  project  beneath  the  stretched  skin,  as  Pitha  puts 
it,  like  a  skeleton  wrapped  in  parchment.  In  two  of  the  author's  cases 
of  outward  dislocation  the  most  striking  symptom  was  the  prominence 
of  the  cubital  process,  which  projected  backward  and  was  easily  recog- 
nizable through  the  stretched  skin.     The  head  of  the  radius  lay  not  to 

•  T I  • 

the  outer  side,  but  in  front  of  the  olecranon,  and  could  be  felt  in  the 
crease  of  the  elbow.  Reduction  was  by  pressure  upon  the  displaced 
ends  of  the  bone  and  traction  on  the  forearm.  In  one  case  of  complete 
outward  dislocation  the  arm  was  extended;  the  internal  epicondyle  was 
torn  off  in  both  cases.     As  a  subvariety  of  this  dislocation,  particularly 


206  INJURIES  OF  THE  ELBOW-JOINT. 

the  outward  form,  should  be  mentioned  complete  rotation-dislocation, 
in  which  the  forearm  is  rotated  on  the  upper  arm  through  180  degrees, 
the  olecranon  thus  facing  forward. 

Forward  Dislocation. — This  form  results  from  direct  violence  upon 
the  olecranon  and  the  forearm  from  behind,  as  by  falling  upon  the  elbow 
with  the  arm  flexed.  The  continuation  of  the  force  resulting  from  the 
weight  of  the  body  drives  the  olecranon  up  in  front  of  the  humerus  and 
it  becomes  fixed.  The  olecranon  is  not  infrequently  broken.  By  experi- 
ments Streubel  demonstrated  various  other  modes  of  production,  such 
as  forced  supination  or  hyperextension  to  a  right  angle.  Marked  flexion, 
as  was  formerly  supposed,  is  not  a  cause.  He  differentiates  an  incom- 
plete forward  dislocation,  in  which  the  tip  of  the  olecranon  rests  against 
the  trochlea,  and  a  complete  dislocation,  in  which  the  posterior  surface 
of  the  olecranon  lies  in  front  of  the  trochlea.  In  the  incomplete  form 
the  forearm  is  lengthened;  the  anteroposterior  diameter  of  the  joint  is 
diminished  rather  than  increased.  On  the  posterior  surface  the  olecranon 
is  absent;  the  end  of  the  humerus  and  the  posterior  supratrochlear  fossa 
are  easily  felt.  The  coronoid  process  is  palpable  in  the  crease  of  the 
elbow  beneath  the  tense  biceps  tendon,  and  at  the  outer  side  a  cleft 
between  the  head  of  the  radius  and  the  external  condyle.  The  arm  is 
only  slightly  flexed.  In  the  complete  form  the  anteroposterior  diameter 
of  the  joint  is  increased.  Behind,  the  cubital  process  is  very  prominent; 
in  front,  the  upper  ends  of  the  bones  of  the  forearm  are  easily  recog- 
nizable. The  few  cases  known  have  made  a  good  recovery  after  reduc- 
tion. Reposition  of  the  incomplete  form  is  not  difficult,  the  tip  of  the 
olecranon  being  freed  from  the  trochlea  by  traction  upon  the  forearm 
in  the  axis  of  the  humerus,  combined  with  gradually  increasing  flexion 
and  subsequent  forward  pressure  on  the  upper  arm.  In  the  complete 
form  the  forearm  is  at  first  strongly  flexed,  as  advised  by  Monin,  and 
then,  with  traction  upon  its  upper  end  in  the  direction  of  the  axis  of  the 
humerus,  it  is  gradually  pushed  under  and  behind  the  cubital  process. 
The  severe  laceration  of  the  capsule  and  lateral  ligaments  which  make 
possible  this  form  of  dislocation  also  facilitate  its  reduction.  The  dis- 
location may  be  accompanied  by  fracture  of  the  olecranon.  The  aim  of 
treatment  is  then  not  only  reposition,  but  also  to  secure  union  of  the 
fracture  by  immobilizing  in  extension.  The  after-treatment  will  be 
found  under  Fracture  of  the  Olecranon. 

Diverging  Dislocations. — In  a  few  instances  backward  dislocation  of 
the  ulna  has  been  seen  associated  with  forward  dislocation  of  the  radius. 
Pitha  regards  the  injury  as  a  wedging  in  of  the  humerus  between  the 
bones  of  the  forearm.  The  annular,  interosseous  and  lateral  ligaments, 
and  the  capsule  are  more  or  less  torn.  The  mode  of  origin  is  not  deter- 
mined. Hofia  regards  the  mechanism  as  that  of  posterior  dislocation, 
modified  by  the  forward  displacement  of  the  radius  after  laceration  of 
the  annular  ligament.  In  experiments  on  the  cadaver  the  dislocation 
is  possible  only  after  division  of  the  ligaments.  The  sagittal  diameter 
of  the  joint  is  increased,  the  ends  of  the  bones  are  easily  felt,  the  arm  is 
slightly  shortened  and  moderately  flexed.    Reduction  is  by  direct  pressure 


DISLOCATIONS  OF  THE  ELBOW.  207 

and  traction  on  the  forearm.     A  few  cases  have  been  seen  in  which  the 
radius  was  displaced  outward,  the  ulna  inward. 

Dislocations  of  One  of  the  Bones  of  the  Forearm. 

Dislocation  of  the  Ulna.  Of  the  isolated  dislocations  of  the  ulna, 
the  only  important  one  is  the  luxation  backward,  as  related  by  A.  Cooper. 
The  ulna  is  displaced  backward  upon  the  trochlea,  the  radius  remains 
in  position.  The  ulnar  side  of  the  arm  is  thus  shortened,  the  forearm 
being  adducted  to  the  varus  position;  the  arm  is  extended  or  flexed 
slightly.  Motion  is  greatly  limited,  rotation  alone  being  possible.  On 
palpation  the  abnormal  position  of  the  olecranon  is  evident.  For  reduc- 
tion simple  traction  may  be  sufficient;  if  difficult,  it  is  best  to  abduct 
the  forearm  and  then  supinate,  corresponding  to  the  mechanism  of  origin 
in  the  cadaver. 

Dislocation  of  the  Radius. — Three  forms  may  be  considered:  for- 
ward, backward,  and  outward.  Forward  dislocation  is  the  common 
form.  It  is  produced  apparently  by  a  fall  upon  the  hand  with  the  arm 
extended,  or  by  hyperextension.  According  to  Streubel,  it  may  be  pro- 
duced in  the  cadaver  by  radial  abduction  with  the  arm  supinated,  thus 
tearing  the  internal  lateral  ligament.  Fracture  of  the  external  condyle, 
of  the  head  of  the  radius,  or  of  the  internal  condyle  may  accompany 
the  dislocation.  Direct  violence  may  be  the  cause,  such  as  a  blow  or  fall 
upon  the  posterior  surface  of  the  elbow,  and  particularly  upon  the  head 
of  the  radius,  slight  flexion  of  the  joint  favoring  the  dislocation.  A  fall 
upon  the  pronated  hand  is  supposed  to  be  equally  frequent  as  a  cause, 
the  forced  pronation  being  the  essential  factor.  In  the  cadaver  the  dis- 
location is  produced  without  difficulty  by  forced  pronation  with  the  arm 
moderately  flexed.  According  to  Loebker,  the  dislocation  results  from 
abduction  or  adduction  of  the  elbow-joint  with  the  arm  pronated  or 
supinated;  forced  pronation  and  adduction  producing  forward  disloca- 
tion, forced  supination  and  abduction  producing  backward  dislocation 
of  the  radius. 

Symptoms. — In  forward  dislocation  the  annular  ligament  is  usually 
torn.  The  head  of  the  radius  lies  beneath  the  supinator  muscles  and  is 
easily  felt  in  front  of  the  external  epicondvle.  Motion  is  limited,  the 
inability  to  flex  beyond  a  right  angle  being  characteristic.  The  forearm 
is  shortened  in  those  not  infrequent  cases  in  which  fracture  of  the  ulna 
in  the  upper  or  middle  third  accompanies  the  dislocation.  In  such  in- 
stances the  symptoms  of  fracture  are  added.  The  picture  may  be  modi- 
fied further  by  fracture  of  the  internal  condyle, and,  according  to  Loebker, 
of  the  external  condyle,  or  by  chipping  off  of  the  head  of  the  radius. 
Reduction  is  not  infrequently  attended  with  difficulties.  If  so,  the  sur- 
geon is  justified  in  assuming,  although  the  anatomical  proofs  are  still 
few,  that  the  disturbing  factor  is  an  interposition  of  the  capsule  or  of 
the  annular  ligament.  Recent  dislocations  often  reduce  easily.  Roser 
hyperextends  the  arm  slightly  with  simultaneous  pressure  upon  the  head. 
Supination  may  help.     On  reduction  the  arm  is  put  up  in  plaster  at  a 


208 


INJURIES  OF  THE  ELBOW-JOINT. 


FiCx.  138. 


right  angle,  the  position  of  best  fixation  for  the  head.  Motion  may  be 
begun  at  the  end  of  fourteen  days.  Operation  is  indicated  if  reduction 
fails.  Sprengel  confines  himself  to  excision  of  the  interposed  parts  of 
the  capsule  and  then  sutures  the  capsule.  Resection  of  the  head  has 
often  given  good  results.  To  avoid  the  radial  nerve,  the  incision  should 
be  lateral,  as  in  this  form  of  dislocation  the  branch  of  the  nerve  always 
crosses  the  head  and  neck  from  in  front.  The  line  of  incision  should  be 
over  the  epicondyle,  as  made  by  Hitter  for  total  resection  of  the  elbow. 
Forward  dislocation  may  be  accompanied  by  fracture  of  the  shaft  of 
the  ulna,  fracture  of  the  external  epicondyle,  oblique  fracture  of  the 

humerus  or  fracture  of  the  outer  por- 
tion of  the  head  of  the  radius,  the  so- 
called  chisel-fracture,  resulting  from 
the  counterpressure  of  the  external 
condyle  against  the  outer  margin  of 
the  head.  The  so-called  "derange- 
ment  interne,"  already  mentioned  as 
occurring  in  children,  is  regarded  by 
many  as  an  incomplete  dislocation  of 
the  radius.  These  injuries  were  de- 
scribed previously  under  fractures. 

The  rare  backward  dislocation  of 
the  radius  results  from  a  fall  upon 
the  hand  with  the  arm  outstretched. 
The  head  is  palpable  at  the  outer 
side  of  the  olecranon;  the  arm  is 
slightly  flexed  and  pronated.  Supina- 
tion, extension,  and  flexion  are  limited. 
The  treatment  is  the  same  as  for  for- 
ward dislocation;  traction  upon  the 
forearm  with  direct  pressure  upon  the 
head,  fixation  for  eight  to  fourteen 
days,  and  then  motion.  Operation 
is  indicated  if  reduction  is  impossible. 
Several  cases  of  outward  disloca- 
tion have  been  observed.  Loebker 
reports  2  instances  in  which  the  pa- 
tient, pushing  a  cart,  was  struck  upon 
the  back  of  the  elbow  by  another 
cart  approaching  from  behind;  the 
arm  was  pronated  and  semiflexed. 
The  head  of  the  radius  projecting 
outward  in  front  of  the  external  condyle  is  easily  recognized  on  inspection 
and  palpation.  Pronation  and  supination  are  often  only  slightly  limited. 
Loebker  in  his  cases  had  to  resect  the  head.  In  a  few  instances  in  which 
reduction  was  not  attempted  or  possible  there  was  a  fair  return  of  motion, 
only  extreme  flexion  being  prevented.  Fracture  of  the  ulna  is  a  rather 
frequent  complication  of  dislocation  of  the  radius,  as  illustrated  in  Fig. 


Outward  dislocation  of  the  head  of  the 
radius  with  fracture  of  the  ulna  in  the  upper 
third.      (Trendelenburg.) 


DISLOCATIONS  OF  THE  ELBOW.  209 

138.  In  this  case  the  radial  nerve  was  paralyzed.  This  combination  is 
produced  by  direct  violence  upon  the  ulna,  the  fracture  resulting  first, 
and  then  the  dislocation;  it  may  he  caused  indirectly  also  by  a  fall  upon 
the  hand.  The  usual  deformity  of  this  combination  is  as  follows,  the 
ulna  is  commonly  fractured  in  the  upper  third;  on  the  radial  side  is  a 
marked  prominence  in  which  the  head  of  the  radius  can  he  felt;  on  the 
posterior  surface  of  the  ulna  is  a  deep  angular  depression  of  the  skin 
the  point  of  which  corresponds  to  the  site  of  fracture  and  from  which 
two  lines  diverge  toward  the  head  of  the  radius  and  toward  the  olecranon. 
The  line  joining  the  head  of  the  radius  and  the  olecranon  is  continued 
laterally  over  the  external  condyle.  Even  though  the  dislocation  is  not 
recognized  or  reduced,  there  is  usually  a  fair  return  of  function.  The 
author  has  seen  several  cases  in  which  only  extreme  supination  and 
flexion  beyond  a  right  angle  were  impossible.  The  power  of  the  hand 
and  of  the  arm  is  almost  normal. 

Treatment. —  By  reduction  of  the  dislocation,  which  is  the  essential 
point,  the  fragments  of  the  ulna  are  replaced  during  the  manipulation 
and  traction  upon  the  forearm.  The  ordinary  plaster  splint  will  main- 
tain the  bones  in  position.  If  the  head  of  the  radius  is  irreducible, 
resection  may  be  necessary. 

The  after-treatment  is  an  important  element  in  the  management  of 
dislocations  of  the  elbow-joint.  Most  of  the  above  forms  of  dislocation, 
except  that  of  the  head  of  the  radius,  require  only  a  short  enforcement 
of  rest,  as  the  ends  of  the  bones,  from  their  form,  maintain  to  a  certain 
extent  the  solidity  of  the  joint.  Passive  motion  should  begin  at  the 
end  of  the  first  or,  at  the  latest,  the  end  of  the  second  week;  it  may  be 
aided  by  mechanical  apparatus  and  should  be  continued  for  some  time. 
The  experience  of  discharging  dislocations  of  the  elbow  as  cured  and 
having  them  return  in  the  course  of  a  few  weeks  fixed  in  a  position  of 
marked  flexion  is  not  unusual.  The  after-treatment,  aided  by  massage, 
should  be  continued,  therefore,  as  long  as  any  inclination  to  ankylosis 
or  cicatricial  contraction  with  limitation  of  motion  is  noticeable.  In 
some  instances  this  may  mean  months. 


Vol.  III.— 14 


CHAPTER   X. 

DISEASES  OE  THE  ELBOW-JOINT. 

ACUTE  SEROUS  AND  PURULENT  INFLAMMATION  OF  THE 
ELBOW-JOINT. 

Acute  Serous  Inflammation. — Acute  non-purulent  inflammation  with 
more  or  less  serous  exudation  in  and  about  the  joint  occurs  in  rheuma- 
tism and  gonorrhoea.  Rheumatic  arthritis  requires  appropriate  internal 
treatment;  only  the  more  chronic  form  with  secondary  stiffness  is  of 
surgical  interest  in  being  amenable  to  mechanical  treatment.  The 
general  symptoms  of  inflammation  of  the  elbow-joint  are  pain,  dimin- 
ished by  rest,  increased  by  motion,  and  tenderness  and  -welling.  Full 
extension  and  flexion  are  impossible  on  account  of  the  pain  even  in 
milder  cases.  The  joint  is  tender  on  pressure,  especially  at  those  spots 
in  which  the  inflamed  synovial  membrane  can  be  pressed  against  the 
underlying  bone.  If  the  swelling  is  great,  the  distended  capsule  bulges 
and  conceals  the  normal  contour  of  the  joint.  Although  the  periarticular 
swelling  generally  conceals  the  intra-articular,  by  careful  palpation  at 
the  head  of  the  radius  and  at  the  sides  of  the  olecranon  behind  one  can 
usually  feel  the  tumor-like  bulging  of  the  capsule  and  obtain  fluctuation. 
This  symptom-complex  of  acute  synovitis  with  periarticular  swelling 
is  not.  characteristic  for  any  particular  affection,  but  may  apply  to 
rheumatic,  gonorrheal,  and  syphilitic  lesions  as  well  as  traumatic 
arthritis  and  joint  diseases  of  nervous  origin.  To  determine  the  etiology 
of  the  synovitis  all  the  accompanying  symptoms  must  be  taken  into 
account. 

Treatment. — The  surgical  treatment  of  the  different  forms  of  syno- 
vitis can  be  embraced  in  a  few  words.  The  rheumatic  form,  to  pre- 
vent subsequent  stiffness  and  contractures,  requires  massage,  hot-water 
or  sand  baths,  hot-air  baths,  passive  motion.  These  measures  are 
equally  valuable  for  other  diseases  of  the  joint  producing  a  tendency 
to  ankylosis.  Gonorrheal  arthritis  of  the  elbow  is  rare;  here  as  in 
other  joints  it  is  inclined  to  produce  ankylosis,  partly  by  reason  of 
the  severity  of  the  periarticular  inflammation.  That  the  gonococcus  is 
the  cause  of  the  frequently  obdurate  inflammations  is  proved  by  a 
series  of  bacteriological  investigations  of  the  exudate.  Of  the  milder 
forms  of  gonorrhoeal  arthritis,  many  recover  without  any  particular 
treatment  except  rest.  If  the  process  is  protracted,  aspiration  may  be 
advisable,  and  finally  the  injection  of  tincture  of  iodine  (3  to  4  c.c), 
or  carbolic  acid  (2  to  3  c.c.  of  a  1  per  cent,  solution).  For  such  cases 
the  "forced-heat"  treatment  is  of  value,  in  which  uniformity  of  temper- 

*(  210) 


PURULEST  INFLA  MM  A  TION  OF  THE  ELBo  W-JOINT.         211 

ature  and  persistence  in  its  application  are  essential.  The  source  of 
heat  is  immaterial;  the  temperature  should  be  about  45°  C.  The  elbow- 
is  more  accessible  for  such  treatment  than  almost  any  other  joint. 
One  may  use  Quincke's  stove-pipe  appliance,  as  suggested  by  Krause, 

or  according  to  Bier  a  wooden  box,  or  the  author's  method  of  enveloping 
the  joint  in  plaster  and  around  this  coiling  lead  pipe  through  which  hot 
water  is  siphoned.  [The  Sprague  hot-air  apparatus  is  widely  used  in 
America  in  hospital  and  clinical  practice.  The  sand-box  can  be  used 
by  the  more  intelligent  poor  in  their  homes  to  great  advantage  if  they 
are  properly  instructed.] 

As  in  rheumatism  and  gonorrhoea,  an  inflammation  of  the  elbow-joint 
may  occur  in  the  course  of  other  general  infections,  e.  r/.,  in  the  infectious 
diseases,  scarlet  fever,  diphtheria,  dysentery,  sepsis,  pyaemia,  typhus, 
variola,  puerperal  fever,  pneumonia,  erysipelas,  and  osteomyelitis.  As 
a  rule,  at  the  onset  of  effusion  in  these  cases  the  treatment  should 
be  expectant;  in  the  event  of  fever,  marked  redness,  tenderness,  or 
phlegmonous  swelling,  pointing  to  a  seropurulent  effusion,  exploratory 
puncture  is  indicated,  and  if  necessary  incision,  drainage,  and  irriga- 
tion. 

Syphilitic  Arthritis. — Either  in  the  pure  serous  or  gummatous  form 
syphilitic  arthritis  is  rare  except  in  children  with  congenital  lues.  The 
etiology  of  the  first  form,  which  corresponds  more  to  a  chronic  hydrar- 
throsis, is  easily  overlooked  in  the  absence  of  any  history  and  accom- 
panying secondary  manifestations  pointing  to  the  catise.  The  gum- 
matous form  is  more  often  mistaken  for  tuberculosis.  In  the  event  of 
other  signs  pointing  to  syphilis  the  diagnosis  is  not  difficult,  still  in  many 
cases  we  will  require  a  bacteriological  examination  or  even  inoculation. 
Doubtful  cases  of  this  form  of  arthritis  always  call  for  a  differential 
diagnosis  ex  juvantibus.  In  the  case  of  children  it  is  well  to  give  sub- 
limate baths  of  1  :  10,000  besides  inunctions.  A  form  of  specific  infec- 
tion termed  syphilitic  osteochondritis  appears  in  early  infancy  in  con- 
genital lues,  and,  according  to  YVegner,  attacks  preferably  the  elbow- 
joint.  The  epiphyses  are  loosened  by  a  growth  of  granulation-tissue  and 
become  separated,  giving  the  clinical  picture  of  paralysis.  The  patient 
does  not  move  the  arms,  so  that  they  hang  relaxed  as  if  paralyzed. 
Acute  serous  synovitis  resulting  from  injury,  sprain,  fracture,  or  dislo- 
cation, assumes  the  form  of  a  chronic  traumatic  hydrops  less  frequently 
here  than  in  the  knee-joint.  In  general  the  elbow-joint  has  a  greater 
tendency  to  adhesive  inflammations,  so  that  stiffness  and  ankylosis 
result  more  frequently  than  serous  inflammation  from  trauma.  The 
prophylaxis  of  such  cicatricial  stiffening  of  the  joint  was  mentioned 
under  Fractures  and  Dislocations.  The  less  frequent  serous  synovitis 
requires  rest  and  possibly  injection  of  iodine. 

Purulent  Inflammation. — Purulent  inflammation,  aside  from  the 
metastatic  inflammations  of  the  infectious  diseases,  is  commonly  the 
result  of  penetrating  wounds  of  the  joint  and  compound  fractures;  it 
may  result  from  direct  transmission  of  an  osteomyelitic  process  in  the 
forearm  or  upper  arm,  exceptionally  from  cellulitis.     Purulent  arthritis, 


212  DISEASES  OF  THE  ELBOW-JOIST. 

recognizable  bv  marked  tenderness,  fluctuation,  redness,  and  inflam- 
matory  swelling  about  the  joint,  and  by  high,  constant  or  intermitting 
fever,  demands  energetic  interference  regardless  of  its  origin.  If  the 
inflammation  follows  a  perforating,  punctured,  incised,  or  stab  wound, 
there  is  usually  a  profuse  discharge  from  the  wound  mingled  with 
synovial  fluid.  The  arm  should  be  elevated,  and  if  necessary  suspended 
vertically  in  a  Volkmann  splint.  The  wound  if  small  should  be  enlarged 
and  drained.  As  retention  occurs  easily  in  the  numerous  recesses  of 
the  elbow-joint,  a  counteropening  should  be  made  early,  preferably  on 
the  posterior  surface  at  the  side  of  the  olecranon.  In  most  of  the  cases 
it  is  immaterial  whether  one  uses  an  antiseptic— carbolic  acid,  salicylic 
acid,  lysol,  bichloride — or  not  in  irrigating.  The  same  treatment  applies 
to  purulent  arthritis  resulting  from  a  compound  fracture. 

If  the  suppuration  is  profuse  and  drainage  still  insufficient  in  spite 
of  numerous  incisions,  the  question  of  resecting  parts  of  the  bones  to 
obtain  free  drainage  arises,  and  how  far  such  resection  should  be  carried. 
It  is  self-evident  that  a  total  resection  here  is  not  indicated,  or  rather 
not  necessary,  as  sufficient  drainage  can  be  obtained  by  partial  re- 
section. Total  resection,  further,  always  presents  the  possibility  of  a 
loose  joint.  The  removal  of  the  lower  end  of  the  humerus  is  really  the 
only  proper  procedure.  The  experience  of  v.  Bruns  in  employing 
partial  resection  of  the  lower  end  of  the  humerus  for  the  cure  of  anky- 
losis demonstrates  that  this  form  of  resection  gives  the  best  functional 
results,  and  is  equally  applicable  to  purulent  inflammation  of  the  joint, 
the  operation  being  performed  through  a  lateral  longitudinal  incision 
or  through  the  wound.  The  idea  of  an  intermediary  resection  founded 
upon  the  old  views  of  infection  does  not  retain  its  former  significance 
at  the  present  time.  The  author  resects  when  according  to  the  course 
of  the  disease  he  considers  it  necessary — in  other  words,  when  the 
general  infection  and  the  local  swelling  and  inflammation  signify  the 
retention  of  pus. 


CHRONIC   INFLAMMATION  OF  THE  ELBOW-JOINT. 

Of  the  chronic  inflammations  of  the  joint,  except  tuberculosis,  brief 
mention  will  be  made  only  of  the  gouty  and  deforming  variety  and  the 
changes  of  neuropathic  origin. 

Gouty  changes  in  the  elbow-joint  may  cause  urates  to  be  deposited  in 
or  about  the  joint.  The  severe  forms  of  arthritis  deformans  are  not 
very  frequent  in  the  elbow,  but  growth  and  thickening  of  the  bone, 
although  commonly  not  very  extensive,  may  result  from  trauma,  espe- 
cially intra-articular  fractures.  In  such  instances  the  superficial  head 
of  the  radius  may  be  felt  as  a  broad  mushroom-like  bony  ring.  The 
synovial  membrane  may  be  increased  in  the  form  of  villous  and  den- 
dritic growths  similar  to  those  characteristic  of  arthritis  deformans  after 
the  chipping  off  of  small  portions  of  the  joint-surfaces.  In  the  advanced 
stages  of  arthritis  deformans  the  pain  produced  by  motion  is  best  alle- 


CHRONIG  INFLAMMATION  OF  THE  ELBOW-JOINT.         ■_>[:', 

viated  by  immobilizing  with  a  circular  splint.  Chronic  inflammatory 
changes  in  the  joint  of  nervous  origin  accompanied  by  atrophy  and 
hypertrophy  may  affect  tin-  elbow,  especially  in  syringomyelia,  which 

attacks  the  upper  extremity  by  choice.  The  lesion  consists  in  a  hydrops 
of  the  joint,  and  extensive  deformation  of  the  articular  ends  with  destruc- 
tion and  hypertrophy  of  the  bone.  The  diagnosis  demands  careful 
examination  of  the  nervous  system.  In  pronounced  cases  the  abnormal 
mobility,  marked  hydrops,  and  the  relatively  slight  pain  denote  the 
neuropathic  origin,  as  first  shown  by  Charcot.  These  lesions  are  appar- 
ently not  trophic  but  of  a  traumatic  nature,  the  severe  grade  of  inflam- 
mation being  due  to  the  inability  of  the  patient  to  protect  the  joint  by 
reason  of  the  anaesthesia  or  analgesia.  An  interesting  instance  was 
observed  in  the  Thiersch  clinic:  there  was  analgesia  of  the  right  hand 
and  forearm  to  the  middle  of  the  upper  arm;  disturbance  of  sensibility 
was  slight;  there  was  marked  thermoana\sthesia;  the  articular  ends 
of  the  bone  were  destroyed  for  about  half  an  inch.  Often  attention 
was  called  to  the  onset  of  the  disease  by  a  surprising  insensibility 
to  external  injury,  such  as  burns,  etc.  In  regard  to  the  treatment  of 
these  chronic  changes  there  is  little  to  be  said.  Apparatus  are  used  as 
in  the  case  of  loose  joints  (which  see)  to  fix  the  joint.  Operation  is 
counterindicated. 

Free  Bodies  in  the  Elbow-joint,— Free  bodies  of  traumatic  origin 
were  discussed  under  fractures,  particularly  under  chisel-fracture  of  the 
radius.  Those  resulting  from  avulsion  may  give  trouble  by  becoming 
wedged  in  the  joint.  The  chipping  off  of  fragments  occurs  rather  fre- 
quently, but  does  not  always  lead  to  the  production  of  free  bodies.  Why 
this  is  so  is  not  known.  The  certainty  that  trauma  is  the  cause  of  many 
free  bodies  has  led  many  authors  to  believe  that  all  free  bodies  are  of 
such  origin.  This  view  is  not  tenable  in  the  face  of  many  observations 
excluding  the  possibility  of  trauma.  Konig  has  demonstrated  that  frag- 
ments such  as  are  usually  found  in  the  case  of  free  bodies  could  hardly 
ever  be  produced  by  experimental  violence.  His  view,  based  upon  large 
personal  material  and  the  later  observations  of  his  assistant,  Martens, 
is,  that  the  majority  of  free  bodies  result  from  pathological  changes 
in  the  bone,  which  he  designates  as  "osteochondritis  dissecans."  It  is 
possible  that  a  slight  injury  may  finally  separate  the  diseased  piece  of 
the  cartilaginous  layer  and  so  make  it  a  free  body.  Barth,  from  his 
investigations,  regards  all  free  bodies  as  fragments  by  trauma,  which 
latter  may  be  very  slight.  Experiments  on  animals  give  no  positive 
proofs  for  this  view,  but  in  most  of  the  author's  cases  the  free  bodies 
were  referable  to  an  injury,  happening  usually  in  youth.  Free  bodies 
in  the  elbow  are  comparatively  frequent;  they  consist  chiefly  of  car- 
tilage; a  few  contain  bone. 

Symptoms. — The  symptoms  of  a  free  body,  characteristic  to  a  certain 
extent,  vary  according  to  its  position.  Bodies  situated  in  the  anterior 
pocket  of  the  joint  give,  according  to  Kocher,  a  characteristic  limitation 
of  motion;  full  extension  falls  short  by  20  to  30  degrees;  sudden  attacks 
of  pain,  the  appearance  of  inflammation,  pain  on  pressure  in  the  fore- 


214 


DISEASES  OF  THE  ELBOW-JOINT. 


part  of  the  joint,  the  palpation  of  a  resistance  and  crepitus  are  diagnostic. 
Bodies  situated  in  the  posterior  supratrochlear  fossa  are  commonly 
symptomless  unless  of  considerable  size. 

Fig.  139  shows  a  beautiful  specimen  of  a  free  body  in  the  posterior 
fossa,  and  Fig.  140  two  small  bodies  in  the  anterior  fossa  of  the  same 


Fig.   140. 


Free  bodv  in  the  olecranon  fossa. 


Two  free  bodies  in  the  coronoid  fossa. 


specimen;  a  defect  in  the  cartilage  is  visible  on  the  eapitulum  which  may 
be  traumatic.  The  history  is  lacking.  Fig.  141  shows  a  free  body  in 
the  coronoid  fossa,  evidently  of  traumatic  origin;  the  patient  as  a  child, 
thirteen  years  ago,  received  an  injury  upon  the  elbow  by  a  fall.  At  the 
present  time  the  loss  of  motion  is  slight,  extreme  flexion  and  extension 

alone  being  limited;  attacks  of  snd- 
Fig.  ]  den  pain  are  rare ;  the  arm  of  ten  feels 

numb.  A  growth  of  callus  on  the 
radius  would  indicate  that  the  free 
body  is  referable  to  a  chipping  off  of 
the  radius  thirteen  years  ago. 

Treatment. — If  removal  of  a  free 
body  is  indicated,  the  site  of  the 
incision  will  depend  upon  the  posi- 
tion of  the  body.  Incisions  on  the 
posterior  surface  for  bodies  situated 
in  the  olecranon  fossa  are  naturally 
very  simple,  and  the  body  easily 
reached.  On  the  anterior  surface  the 
joint  is  less  accessible.  The  incision 
is  made  to  the  inner  side  of  the 
cubital  artery  and  median  nerve;  the 
branches  of  the  internal  cutaneous 
are  easily  protected;  the  fibres  of  the  pronator  teres  are  separated  and 
held  by  blunt  retractors;  the  brachialis  anticus  lying  beneath  is  then  re- 
tracted and  the  capsule  exposed  and  incised.  To  expose  the  joint  at  the 
head  of  the  radius  from  in  front  for  bodies  lying  to  the  outer  side  and  in 
front,  the  incision  is  to  the  outer  side  of  the  biceps  tendon;  the  fibres  of 
the  supinator  longus  are  separated,  the  underlying  radial  nerve  retracted, 


nun iid  fossa. 


CHR  ONIC  INFLA  MM  A  TIOX  OF  Til  E  E I H  0  W-JOINT.  215 

and  the  capsule  incised.     The  results  of  operation  are  very  good;  as  a 

rule  the  restoration  of  motion  is  complete.  The  operation  should  be 
entirely  instrumental  and  the  asepsis  very  thorough.  Konig  reports 
excellent  results  in  his  numerous  operations  for  free  bodies  of  the  elbow. 

Tuberculosis  of  the  Elbow-joint.  -Tuberculous  processes  of  the  elbow- 
joint  are  more  common  in  children,  but  are  observed  after  the  thirtieth 
and  fortieth  year;  they  are  more  frequently  a  local  manifestation  of  gen- 
eral tuberculosis;  women  are  affected  more  often  than  men.  From  the 
statistics  of  the  Berne  clinic,  16  per  cent,  of  the  patients  were  under  ten 
years,  36  per  cent,  under  twenty  years,  19  per  cent,  under  thirty  vears, 
19  per  cent,  under  forty  years.  According  to  Konig,  25  per  cent,  were 
under  ten  years,  20  per  cent,  under  twenty  years,  12  per  cent,  under 
thirty  years,  15  per  cent,  under  forty  years,  8  per  cent,  under  fifty  years, 
14  per  cent,  under  sixty  years,  6  per  cent,  under  seventy  years.  The  point 
of  origin  of  the  affection  with  a  slow  onset  and  course  is  either  the 
synovialis — primary  synovitis,  the  rarer  form,  or  the  bone  adjacent  to 
the  joint — primary  ostitis,  the  usual  form.  In  137  cases  Konig  found 
71  per  cent,  of  the  latter,  29  per  cent,  of  the  former.  The  primary  osseous 
foci  have  certain  points  of  predilection;  according  to  Kummer  and 
Oschmann,  in  50  of  their  cases  it  was  the  olecranon,  in  33  the  external 
condyle,  in  20  the  internal  condyle,  and  in  20  the  lower  end  of  the 
humerus. 

Symptoms  and  Course. — The  course  is  usually  slow;  small  osseous 
foci  in  the  neighborhood  of  the  joint  mav  remain  latent  for  a  long  time 
or  be  manifested  merely  by  circumscribed  swelling  and  tenderness  over 
the  olecranon  or  the  condyles,  according  to  their  position.  Often  the 
real  inflammation  of  the  elbow  will  be  first  noticeable  after  the  bony 
focus  has  perforated  into  the  joint.  Not  infrequently  this  follows  a  slight 
injury,  the  latter  on  this  account  being  regarded  as  the  cause  of  the 
disease.  The  joint-infection  once  established  with  effusion  is  recog- 
nizable by  the  evident  protrusion  of  the  capsule  at  the  head  of  the 
radius  and  posteriorly  at  the  sides  of  the  triceps  tendon;  this  is  accom- 
panied by  periarticular  cedema,  and  later  the  spindle-form  of  the  so- 
called  "white  swelling"  gradually  develops  with  atrophy  of  the  muscles 
of  the  upper  and  forearm.  With  involvement  of  the  synovialis  the  func- 
tion of  the  joint  is  more  and  more  disturbed  and  limited.  Motion,  also 
pronation  and  supination,  is  moderately  painful.  If  the  synovialis  is 
involved  at  the  onset,  the  impairment  of  motion  develops  more  gradually; 
only  the  greater  excursions  are  painful;  later,  swelling  and  pain  slowly 
increase.  Fig.  142  shows  a  characteristic  spindle-form  deformity  of 
tuberculosis  of  the  elbow;  the  child  had  a  simultaneous  spina  ventosa 
of  the  left  middle  finger;  Fig.  143  shows  the  recovery  after  injection  of 
iodoform. 

In  the  later  stages  of  the  process  there  is  usually  a  tendency  to 
the  formation  of  abscesses  and  fistulas.  The  pure  fungous  form  is  much 
less  frequent  than  the  suppurating;  according  to  Kosima,  53  per  cent, 
of  all  cases  result  in  fistulas.  The  fistulas  are  situated  either  upon  the 
condyles  or  the  olecranon  or  open  upon  the  posterior  surface  between 


216 


DISEASE*  OF  THE  ELBOW-JO  I  XT. 


the  radius  and  ulna;  gravitation  abscesses  develop  secondary  to  those 
about  the  joint,  advancing  down  the  forearm.  Extensive  destruction 
of  the  capsule,  ligaments,  and  cartilage  gives  rise  to  false  mobility,  the 
joint  yielding  to  lateral  movements,  often  with  elastic  resistance.  Many 
eases  of  tuberculosis  are  not  seen  in  the  incipient  stage,  but  "after  a 
marked  tumor  has  developed  and  the  synovialis,  bones,  cartilage,  and 
ligaments  have  become  involved. 

Prognosis. — It  is  clear  that  in  view  of  the  great  difference  in  the  forma- 
tion and  development  of  tuberculous  processes  a  positive  prognosis  is 


Fig.  142. 


Fig.  143. 


Fungous  tuberculosis  of  the  elbow-joint, 
(v.  Bruns.) 


lame  cured  by  iodoform  injection. 
(v.  Bruns.; 


impossible.  There  is  no  doubt  that  tuberculous  affections  of  this  joint 
may  recover  without  any  treatment,  or  at  the  most  with  immobilization, 
in  that,  as  in  all  such  processes  of  recovery,  a  growth  of  connective  tissue 
encloses  the  tuberculous  granulations  and  replaces  them.  It  is  impossible 
to  estimate  how  many  tuberculous  processes,  which  perhaps  develop  up 
to  the  stage  of  a  hydrops,  heal  spontaneously.  It  remains  therefore  to 
consider  the  prognosis  of  the  cases  appearing  for  treatment  in  a  more 
or  less  advanced  stage.  It  is  evident  that  those  only  slightly  advanced, 
especially  those  in  which  the  joint  is  still  little  involved,  stand  a  better 
chance  of  recovery,  both  on  account  of  the  limitation  of  the  process  as 
well  as  the  better  general  condition,  than  the  fistulous  cases  with  extensive 


CHRONIC  INFLAMMATION  OF  THE  ELBOW-JOINT.         217 

involvement.  All  authors  arc  agreed  that  the  prognosis  as  to  life  is  good 
provided  there  are  no  tuberculous  t'oei  elsewhere.  As  to  the  function,  the 
results  vary  enormously.  As  to  the  results  of  the  various  therapeutic 
measures,  the  views  of  many  authors,  although  generally  favorable,  are 
not  in  accord. 

Treatment. — Of  the  different  methods  <>|'  treatment  extant,  the  author 
will  describe  the  following:  injection  of  iodoform;  passive  congestion; 
operative  interference,  extensive  or  slight;  evidement,  partial  resection; 
arthrectomy;  total  resection.  Iodoform  is  generally  recognized  as  of 
unquestionable  value  in  tuberculous  processes,  especially  tuberculosis 
of  the  elbow.  The  exposed  position  of  the  joint  allows  of  the  injection  of 
iodoform  on  all  sides,  and  the  joint  is  especially  accessible  in  spite  of  the 
fact  that  its  complicated  form  is  not  particularly  favorable  for  the  dis- 
tribution of  the  iodoform  within.  The  method  in  general  use  at  present 
is  the  injection  of  a  10  per  cent,  solution  of  iodoform  in  glycerin;  in  the 
Leipzig  clinic  an  oil  emulsion  of  iodoform  is  used.  Although  the  manner 
of  application  is  practically  the  same  everywhere,  a  great  difference  of 
opinion  exists  as  to  which  forms  of  the  disease  are  indication  for  this 
treatment;  some  authors  go  so. far  in  conservative  surgery  as  to  employ 
injection  in  the  widest  extent  possible;  others  advise  early  energetic 
operative  treatment.  For  the  incipient  stage  of  "white  swelling,"  as  it 
is  commonly  seen  in  practice  among  the  poorer  classes,  the  treatment  is 
somewhat  as  follows:  For  injection  one  needs  a  large  needle  and  a 
graduated  syringe  to  hold  about  10  c.c;  the  skin  being  cleansed  and 
sterilized,  the  needle  is  inserted  into  the  joint  at  the  most  accessible 
points,  at  the  head  of  the  radius,  at  the  side  of  the  olecranon,  or  beneath 
the  internal  condyle.  The  needle  should  be  inserted  obliquely  through 
the  skin  and  then  straight  into  the  joint,  so  that  the  skin  acts  as  a  valve 
over  the  joint-wound.  In  children  up  to  the  fourth  or  fifth  year,  the 
author  injects  3  to  4  c.c.  at  one  spot  or  in  several  places;  in  older  children 
the  dose  can  be  increased  to  8  to  10  c.c.  Slight  movement  of  the  joint 
aids  distribution  of  the  injection.  The  arm  is  then  immobilized  in  a 
strip  splint.  At  the  end  of  twenty-four  hours  there  is  usually  marked 
irritation  about  the  joint  and  slight  fever.  The  result  of  the  first  injection 
is  watched  quietly  and  the  joint  is  left  undisturbed  for  eight  to  ten  days. 
If  the  reaction  subsides,  the  injection  is  repeated  in  about  fourteen  days. 
By  this  simple  method  it  is  possible  to  limit  the  process  by  three  to  four 
injections  so  that  it  gradually  cicatrizes  and  heals  without  recurrence. 
Fig.  143  shows  a  patient  with  the  white  swelling  as  represented  in 
Fig.  142,  recovering  with  good  motion  after  injection  of  iodoform. 
If  the  process  has  advanced  to  the  formation  of  cold  abscesses,  the  con- 
tents of  the  latter  should  be  aspirated  and  then  the  iodoform  injected; 
fistulas  if  present  may  also  be  injected.  Where  the  fistulas  are  multiple 
they  should  be  closed  during  the  injection  to  force  the  iodoform  all 
through  by  pressure,  v.  Mikulicz  in  injecting  fistulas  uses  a  syringe 
with  an  olivary  tip  corresponding  to  the  size  of  the  opening,  to  prevent 
reflux  of  the  emulsion.  For  fistulas  as  well  as  for  the  remaining  forms 
of  fungous  inflammation,  it  is  beneficial  to  inject  the  surrounding  tissues 


218  DISEASES  OF  THE  ELBOW-JOINT. 

instead  of  the  foci.  If  the  fistulas  are  large,  the  iodoform  may  be  retained 
by  tamponing.  As  iodoform  is  impervious  to  the  a;-ray,  the  results  of 
injection  can  be  controlled  by  the  fluoroscope.  Slight  intoxication  with 
psychical  disturbances,  etc.,  has  been  observed  occasionally  after  injec- 
tion; death  from  such,  however,  is  of  rare  occurrence.  The  injection  of 
other  antiseptics,  such  as  a  3  per  cent,  solution  of  carbolic  acid,  cinnamic 
acid,  etc.,  has  been  recommended,  but  has  proved  inferior  to  iodoform. 
Opinion  varies  as  to  which  cases  of  tuberculosis  of  the  elbow  are  suitable 
for  the  iodoform  treatment;  the  author's  experience  up  to  the  present 
time  would  indicate  the  value  of  first  trying  the  iodoform  treatment  in 
all  instances  in  which  the  disease  is  not  far  advanced;  and  in  fact  the 
obligation  is  to  try  it,  according  to  the  view  of  nearly  all  authors,  in 
children,  in  whom  a  major  operation  is  certain  to  cause  disturbances  in 
growth.  If  at  the  end  of  four  or  at  the  most  six  weeks  the  treatment 
gives  no  improvement,  energetic  measures  should  not  be  delayed  or  the 
period  neglected  in  which  minor  operations  still  promise  benefit.  If 
the  inflammation  is  the  more  frequent  osseous  form,  the  surgeon  may 
confine  himself  here  also  at  first  to  the  iodoform  treatment:  but  even 
in  this  case  it  is  advisable,  if  the  bony  focus  can  be  demonstrated  posi- 
tively by  the  .r-rays  or  otherwise,  to  scrape  out  the  focus  in  order  to 
remove  small  sequestra. 

Before  proceeding  to  the  minor  and  major  surgical  operations  of  the 
joint,  the  treatment  by  passive  congestion,  as  first  applied  by  Bier 
in  1892,  should  be  mentioned.  Opinion  is  divided  as  to  its  results;  in 
some  instances  it  has  enthusiastic  advocates  and  has  given  excellent 
results;  in  others  it  failed  completely.  Its  proper  valuation  lies  between 
the  two  extremes,  and  to  the  author  appears  properly  designated  by  v. 
Mikulicz,  who  regards  the  congestion  method  as  an  aid  to  iodoform 
treatment.  The  method  consists  in  constricting  the  upper  arm  with  a 
Martin  rubber  band  applied  over  gauze;  the  constriction  should  be  only 
sufficiently  tight  to  check  the  venous  flow.  The  hand  and  forearm  are 
enveloped  in  a  muslin  or  flannel  bandage;  the  joint  is  left  free.  The 
region  of  the  joint  becomes  cyanotic;  the  joint  swells  and  becomes 
oedematous;  the  granulations  and  the  fistulas  swell  and  become  glisten- 
ing and  bluish.  The  congestion  should  be  continued  for  fourteen  to 
eighteen  hours  daily,  and  repeated  if  well  borne.  In  several  days  the 
granulations  are  often  covered  with  a  thick  eschar  as  in  beginning 
necrosis.  Occasionally  the  tuberculous  process  appears  to  grow  worse 
during  the  first  few  days;  soon  after  removal  of  the  constriction  the  swell- 
ing subsides,  however,  motion  becomes  freer,  and  healing  commences. 
Passive  congestion  has  not  been  extensively  applied  to  the  elbow,  so 
that  a  definite  estimation  of  its  value  is  impossible.  It  is  certain  that  it 
often  exercises  a  beneficial  influence  upon  the  pain,  which  diminishes 
rapidly  and  permits  apparently  of  freer  motion.  There  is  no  evidence 
to  show  that  the  application  of  congestion  alone  at  the  beginning  of  the 
disease  can  cure  tuberculous  inflammation.  Failures  are  unquestionable ; 
sometimes  the  treatment  is  badly  borne;  if  so,  time  should  not  be  wasted 
in  further  attempts.     Bier  admits  that  in  his  experience  the  formation 


CHRONIC  INFLAMMATION  OF  THE  ELBOW-JOINT.  219 

of  cold  abscesses  took  place  first  under  the  influence  of  congestion,  a 
result  which  he  regards  as  favorable. 

It  has  been  already  mentioned  that  in  children  the  treatment  should 
be  as  conservative  as  possible,  and  should  begin  with  the  injection  of 
iodoform,  possibly  combined  later  with  congestion.  In  adults  partial 
or  total  resection  is  more  appropriate.  Surgical  interference  is  more 
readily  carried  out  on  the  elbow,  in  which  the  bones  are  easily  felt,  and 
in  which  the  frequent  primary  osseous  foci  are  easily  determined  by  the 
.r-ray,  than  on  other  joints.  Minor  operations  for  the  removal  of  carious 
spots  in  the  bone,  as  by  scraping,  are  here  simple.  Konig  and  Kocher, 
the  two  most  enthusiastic  advocates  of  operative  treatment  for  tubercu- 
losis of  this  joint,  recommend  early  incision  and  scraping  of  such  carious 
foci.  If  small  fistulas  persist,  it  is  advisable,  after  scraping  out  the  foci, 
removing  sequestra,  and  dusting  the  cavity  with  iodoform,  to  close  the 
skin-wound  in  order  to  secure  primary  union  and  avoid  the  secondary 
infection  which  often  complicates  tuberculosis  and  retards  recovery.  If 
the  process  cannot  be  limited  by  such  minor  procedures  because  the 
joint-involvement  has  advanced  too  far,  more  comprehensive  measures 
are  necessary.  At  the  present  time  the  rules  followed  are  different  from 
those  observed  formerly,  when  in  such  instances  total  resection  was 
employed  according  to  the  teaching  of  this  or  that  school.  Now  the 
duty  of  the  operator  is  to  avoid  every  set  scheme  in  resecting  and  to 
modify  according  to  the  nature  of  the  case. 

For  tuberculosis  of  the  synovialis  simple  arthrectomy  is  often  suffi- 
cient; the  joint  is  exposed  by  one  of  the  incisions  to  be  mentioned  later 
under  resection,  and  the  cavity  opened  so  that  it  may  be  examined  easily; 
all  tuberculous  granulations  are  removed  with  scissors  and  sharp  spoon, 
and  any  diseased  cartilage  excised.  By  arthrectomy  is  meant  the  removal 
of  the  capsule  and  cartilaginous  disks.  Kocher  regards  extirpation  of 
the  capsule  as  the  chief  purpose  of  arthrectomy;  as  a  rule  he  does  not 
advance  directly  into  the  joint,  but  dissects  around  the  outer  surface 
of  the  capsule,  frees  the  same  and  removes  it  en  masse.  The  removal 
of  portions  of  diseased  bone  will  depend  upon  the  conditions  found  on 
opening  the  joint.  It  will  often  be  necessary  in  connection  with  arthrec- 
tomy to  scrape  out  small  spots*  or  do  a  partial  resection ;  a  more  or  less 
complete  resection  will  be  unavoidable  if  the  bones  are  involved  exten- 
sively. For  the  details  of  total  resection,  see  the  following  chapter. 
Konig  gives  the  following  statistics:  complete  resection — complete  recov- 
ery, 54  per  cent.;  incomplete  recovery,  8  per  cent.;  deaths,  38  per  cent.; 
incomplete  resection  and  Other  treatment — complete  recovery,  32  per 
cent.;  incomplete  recovery,  8  per  cent. ;  deaths,  61  percent.  The  func- 
tional results  were  as  follows:  in  45  cases  with  complete  recovery  follow- 
ing complete  resection,  in  40  of  which  he  used  v.  Langenbeck's  method, 
in  the  other  5  his  own,  there  was  60  per  cent,  of  recoveries  with  more 
or  less  motion  and  good  power,  33  per  cent,  with  ankylosis  and  satis- 
factory power,  7  per  cent,  with  loose  joint.  Kocher  obtained  a  good 
working  arm  and  hand  even  for  hard  work  in  64  per  cent.,  and  a 
capacity  for  only  light  work  in  36  per  cent. 


220 


DISEASES  OF  THE  ELBOW-JOINT. 


Fig.  144. 


From  these  statistics  no  general  conclusions  can  be  drawn  as  to  the 
advantages  of  the  individual  operations,  although  these  data  are  the 
results  obtained  by  experienced  surgeons,  and  are  the  best  up  to  the 
present  time.  At  any  rate,  in  spite  of  the  good  results  of  purely  conser- 
vative methods  there  is  no  doubt  that  a  broad  field  lies  open  for  total 
resection  in  the  case  of  tuberculosis  of  the  elbow,  and  that  the  procedure 
is  capable  of  giving  good  results.  It  is  demanded  for  the  severe  forms 
with  extensive  fistulas  and  for  those  cases  in  which  conservative  treat- 
ment has  failed  either  because  the  process  has  not  reacted  favorably  to 
iodoform  treatment  or  because,  on  account  of  the  fungous  form  of  the 
disease,  the  iodoform  could  not  be  distributed  through  the  joint,  the 
process  advancing  in  one  place  while  healing  in  another. 

Partial  resection  is  always  to  be  preferred  to  total  resection  where  the 
process  is  limited.  If,  for  example,  on  opening  the  joint  the  chief  focus 
is  found  in  the  lower  end  of  the  humerus,  resection  can  be  limited  to 
the  cubital  process;  on  the  other  hand,  if  it  lies  in  the  ulna,  the  upper 

ends  of  the  bones  of  the  forearm  are 
removed  and  the  humerus  left  as 
intact  as  possible.  Even  in  partial 
resection  modification  is  possible,  so 
that  it  is  impossible  to  give  a  uniform 
mode  of  procedure  here.  The  author 
would  mention  further  that  in  every 
partial  resection  and  arthrectomy 
where  the  head  of  the  radius  is  ap- 
parently intact,  the  joint  between  the 
head  of  the  radius  and  ulna  should 
be  examined  carefully,  as  tuberculous 
foci  here  are  easily  overlooked.  The 
technic  of  incision  of  the  joint  given 
in  the  following  chapter  applies  also 
to  partial  resection.  As  to  the  pros- 
pects of  success  attending  the  appli- 
cation of  the  procedures  mentioned, 
nothing  definite  can  be  said  a  priori. 
In  general  one  can  advise  the  iodo- 
form treatment  for  incipient  cases, 
eventually  perhaps  Bier's  congestion 
method.  For  the  more  advanced 
stages  the  available  reports  point 
definitely  to  early  operative  interference  in  the  form  of  arthrectomy,  or 
partial  or  total  resection.  The  danger  of  the  much-dreaded  miliary 
tuberculosis  which  occasionally  follows  other  joint-operations  is  not  to 
be  anticipated  with  reference  to  the  el  bow- joint,  for  in  this  case,  accord- 
ing to  the  experience  of  Konig  and  Ivocher,  it  is  an  extremely  rare 
occurrence.  In  children  one  thing  only  can  restrain  the  surgeon  from 
resecting,  namely,  the  disturbance  of  growth.  Fig.  144  shows  an  x-ray 
picture  of  the  arm  of  a  patient  aged  eighteen  years,  upon  whom  total 


Arrested  growth  after  reseetion  of  the 
elbow  fourteen  years  previously.  Youth 
aged  eighteen  years. 


CHRONIC  INFLAMMATION  OF  THE  ELBOW  JOINT.  221 

resection  was  done  in  the  fourth  year  for  tuberculosis  of  the  elbow. 
The  arm  was  markedly  shortened,  the  bones,  as  manifest  in  the  picture, 
considerably  underdeveloped  in  thickness.  Interesting  is  the  crossed 
position  of  the  ulna  and  humerus.  The  patient  can  move  the  elbow 
slightly;  the  hand  is  intact,  but  its  power,  like  that  of  the  entire  arm, 
greatly  reduced.  From  this  it  can  be  understood  how  great  may  be  the 
disturbance  in  growth  following  resection. 


CHAPTER  XI. 

OPERATIONS  ON  THE  ELBOW-JOINT. 


Fig.  145. 


RESECTION  OF  THE  ELBOW-JOINT. 

Indications. — Resection  may  be  necessary  for  severe  suppuration  fol- 
lowing wounds  of  the  joint  or  compound  fractures,  although,  as  has  been 
indicated,  modern  asepsis  justifies  the  most  strenuous  efforts  to  preserve 
the  relations  of  the  normal  joint.  If  a  severe  phlegmonous  inflammation 
of  the  joint  occurs,  and  periarticular  inflammation  and  suppuration 
in  the  joint  cannot  be  checked  in  spite  of  extensive  drainage,  the  sur- 
geon is  compelled  in  such  cases  to  perform  a  partial  or  total  resection. 
In  war  resection  is  more  frequently  advisable  and  necessary  for  severe 

gunshot-fractures.  Further,  it  may 
be  required  for  the  reposition  of  irre- 
ducible dislocations,  as  already  dis- 
cussed, particularly  resection  of  the 
lower  end  of  the  humerus  as  proposed 
by  v.  Bruns.  For  ankylosis  of  the 
joint  resection  is  contraindicated  on 
account  of  the  danger  of  loose  joint, 
except  where  the  position  of  the  arm 
is  faulty  or  the  attempt  to  improve 
the  function  is  desired  by  the  patient, 
partial  resection  being  preferable,  as 
in  the  event  of  failure  the  operation 
may  be  repeated.  The  results  ob- 
tained by  Wolff  in  treating  cicatricial 
ankylosis  and  by  v.  Eiselsberg  in  the 
case  of  irreducible  luxation  without 
resection  and  yet  with  the  production 
of  good  motion,  are  related  in  the 
corresponding  sections.  The  most  fre- 
quent indication  for  resection  is  the 
fungous  form  of  tuberculosis  of  the 
joint,  and  the  nature  and  extent  of 
the  operation  will  depend  obviously  on  the  extent  of  the  process.  All 
authors  are  agreed  in  advocating  preservation  of  healthy  bone  con- 
sistent with  removal  of  all  diseased  portions. 

Of  the  various  methods  of  total  resection,  only  those  of  v.  Langenbeck, 
Oilier,  and  Hiiter  will  be  described.     In  v.  Langenbeck's  operation  the 
forearm  is  flexed  and  rotated  until  the  olecranon  points  upward.     The 
(  222  ) 


Besection  incision.    'After  v.  Langenbeck.  i 


RESECTION  OF  THE  ELBOW  JOINT.  ^2:', 

incision  is  made  over  the  posterior  surface  of  the  olecranon,  extending 
upward  and  downward  about  2  inches  in  both  directions.  (Fig.  L45.) 
The  olecranon  fossa  is  entered  above  the  tip  of  the  bone  and  the  triceps 
split  upward  as  far  as  the  incision.  The  periosteum  is  peeled  off  with  the 
soft  parts,  en  masse  if  possible,  beginning  on  the  inner  side,  either  with  the 
forceps  and  bone-scalpel  or  bystretching  it  with  the  finger-nail  and  cutting 
the  retaining  fibres.  On  the  posterior  surface  of  the  ulna  it  is  easier  to 
lift  off  the  periosteum  and  soft  parts  en  masse  with  the  periosteal  elevator. 
In  loosening  the  tissues  in  the  ulnar  groove,  the  ulnar  nerve  should  be 
guarded  and  pushed  aside  over  the  inner  condyle  with  the  soft  parts. 
The  attachments  of  the  tendons  and  muscles  and  the  internal  ligament 
are  then  separated  from  the  condyle.  On  the  outer  side  the  soft  parts 
are  pushed  over  the  external  condyle  in  the  same  manner,  the  ligaments 
and  muscular  attachments  being  lifted  off  en  masse;  by  flexing  forcibly 
the  joint  can  be  opened  for  inspection.  All  parts  still  tense  are  divided 
and  the  joint  dislocated.  It  is  easier  to  first  saw  off  the  low^er  end  of 
the  humerus  at  the  level  of  the  condyles;  the  upper  ends  of  the  bones 
of  the  forearm  are  protruded,  the  soft  parts  held  back  with  blunt  retrac- 
tors, and  the  bones  sawed  off  below  the  radioulnar  joint — that  is,  beyond 
the  head  of  the  radius.  From  lack  of  space  it  may  be  necessary  to 
remove  the  upper  end  of  the  forearm  first.  If  the  caries  extends  beyond 
the  sawed  surface,  the  foci  are  scraped  out  to  sound  bone.  This  com- 
pletes the  operation  as  performed  by  v.  Langenbeck;  but  Konig's  demon- 
stration of  the  involvement  of  the  synovialis  in  the  process  presents  a 
further  and  important  task  in  the  removal  of  the  entire  capsule  and  all 
granulation-tissue,  the  latter  recognizable  by  its  glazed  appearance.  The 
joint  should  be  cleansed  thoroughly  of  all  tuberculous  tissue  with  forceps 
and  scissors  or  scalpel  and  sharp  spoon.  The  majority  of  operators 
then  dust  the  joint  with  iodoform,  suture  and  drain.  It  is  best  to 
remove  the  tourniquet  before  applying  the  splint,  and  to  ligate  any 
bleeding  points.  Konig  applies  the  splint  first  and  then  removes  the 
constriction;  in  his  experience  bleeding  is  slight.  The  arm  is  bandaged 
in  semiflexion;  strips  as  formerly  employed  by  Esmarch  are  not  neces- 
sary, as  the  ordinary  dressing  with  or  without  the  incorporation  of  wood 
or  paper  strips  is  sufficient  to  fix  the  arm.  The  latter  is  elevated  and 
steadied  with  sand-bags  or  pillows;  v.Volkmann's  suspension  splint  is  ser- 
viceable. A  strictly  subperiosteal  resection,  as  emphasized  by  v.  Langen- 
beck, is  not  regarded  as  essential  at  the  present  time;  in  some  instances 
portions  of  the  periosteum  should  be  removed  rather  than  leave  any 
diseased  tissues  behind.  On  the  other  hand,  where  the  bone  is  normal 
and  the  presence  of  certain  bony  points  of  support  are  essential  for  the 
subsequent  function,  the  author  leaves  more  than  the  periosteum;  for 
example,  at  the  epicondyles  the  soft  parts  are  not  separated  off,  but  a 
flat  disk  of  the  bone  is  chiselled  off  with  them  to  leave  a  firm  base  of 
attachment  for  the  muscles.  For  the  same  reason  it  is  important  to 
preserve  a  part  of  the  olecranon ;  Kocher  does  this  through  the  incision 
recommended  by  Oilier,  first  sawing  off  the  head  of  the  radius  and 
then  sawing  the  ulna  from  before  backward,  making  a  curved  section 


224 


OPERATIONS  ON  THE  ELBOW-JOINT. 


Fig.  146. 


and  leaving  the  posterior  part  of  the  olecranon  intact;  an  artificial 
sigmoid  fossa  is  thus  made.  For  several  years  he  has  sought  to  produce 
the  same  result  by  chiselling  off  the  superficial  lamina  of  the  olecranon 
to  which  the  triceps  is  attached;  to  do  this,  the  incision  is  made  to  the 
inner  side  of  the  line  given  by  v.  Langenbeck.  This  modification  of  the 
resection  is  very  important  for  extension;  further,  Kocher  claims  that 
it  is  an  excellent  means  of  preventing  the  forward  dislocation  occurring 
easily  after  resection. 

The  so-called  bayonet  or  Z-incision  was  first  proposed  by  Chassaignac, 
later  by  Oilier,  and  is  widely  used.  (Tig.  146.)  The  incision  begins  at 
the  outer  edge  of  the  triceps  and  the  inner  border  of 
the  supinator  longus,  extends  to  the  external  con- 
dyle, bends  sharply  toward  the  tip  of  the  olecranon, 
and  is  continued  from  there  directly  downward 
upon  the  olecranon.  With  the  arm  flexed  at  45 
degrees,  the  incision  is  deepened  down  to  the  bone; 
the  oblique  cut  strikes  the  anconeus;  Oilier  sepa- 
rates this  from  the  triceps  tendon.  The  latter  is 
detached  with  the  periosteum  from  the  ulna  and 
drawn  side;  in  dividing  the  capsule  behind,  the 
portion  over  the  external  condyle  and  the  head  of 
the  radius  should  be  left  intact  as  far  as  possible. 
The  capsule  is  now  exposed  on  the  inner  side  be- 
hind and  beneath  the  internal  condyle;  the  arm 
should  not  be  flexed  too  much;  the  capsule  on  the 
posterior  surface  is  excised  and  the  joint  opened  by 
flexing  forcibly.  The  anterior  part  of  the  capsule 
is  removed  with  the  scissors  and  the  ends  of  the 
bones,  easily  accessible,  are  sawed  off. 

The  bilateral  incision  of  Hiiter  gives  a  good  view 
of  the  joint,  and  is  applicable  both  for  total  resec- 
tion for  fungous  inflammations  as  well  as  for  partial 
resection.  Hiiter  incises  first  at  the  tip  of  the  internal  epicondyle, 
and  from  it  frees  the  attachments  of  the  muscles  and  ligaments;  on 
the  radial  side  he  begins  the  incision  a  little  above  the  point  of  the 
external  epicondyle  and  continues  it  downward  for  about  3  or  4  inches; 
the  lateral  and  annular  ligaments  are  incised  over  the  head  of  the  radius, 
the  neck  laid  bare  with  the  knife  and  elevator,  and  the  head  removed 
with  a  pointed  saw.  The  attachment  of  the  capsule  is  put  on  the  stretch 
by  introducing  the  finger  beneath  it  and  the  capsule  divided  in  front 
and  behind.  The  end  of  the  humerus  is  now  dislocated  outward  and 
sawed  off.  In  like  manner  the  ulna  is  protruded  and,  after  subperiosteal 
elevation  of  the  triceps  insertion,  its  upper  end  is  removed  with  the  saw. 
Trendelenburg  frequently  chisels  off  the  olecranon,  completes  the  resec- 
tion of  the  joint  and  the  removal  of  all  diseased  tissue,  and  then  sutures 
the  olecranon  back  in  place. 

As  to  the  after-treatment:  Konig  applies  the  fixation  splint  with  the 
forearm  extended;  in  fourteen  days  the  stitches  are  removed;  in  four 


Resection  incision. 
(After  Oilier.) 


RESECTION  OF  THE  ELBOW-JOINT. 


225 


weeks  the  arm  is  flexed,  eventually  under  anaesthesia.    The  hand  should 

be  immobilized  in  supination.  As  soon  as  the  wound  has  healed  gentle 
passive  movements  should  he  begun.  Electricity,  massage,  etc.,  are 
beneficial.  Kocher  emphasizes  the  importance  of  careful  after-treat- 
ment, even  to  the  slightest  details,  to  prevent  a  loose  joint  or  ankylosis. 
He  tampons  the  cavity;  in  eight  days  the  tampons  are  removed;  in 
fourteen  the  wound  is  usually  healed.  The  first  position  of  the  forearm 
in  the  splint  after  operation  is  very  essential  for  its  later  conformation; 
any  lateral  or  forward  displacement  must  be  avoided,  as  both  positions 
favor  the  formation  of  a  loose  joint.  To  secure  a  fibrous  covering  over 
the  ends  of  the  bones,  the  latter  are  kept  apart  and  brought  into  their 
normal  position  first  at  the  end  of  from  ten  to  fourteen  days;  this  is 
supposed  to  prevent  bony  ankylosis.  To  favor  the  formation  of  the 
joint  subsequent  to  operation,  passive  motion  should  not  be  commenced 
too  soon,  but    rather  the   mobility 

of  the  joint  in  the  normal  direction  '  If  ■  14~- 

guided  by  means  of  an  apparatus. 
The  latter  should  be  applied  as  soon 
as  possible,  and  consists  of  two 
sheaths  to  encircle  the  forearm  and 
upper  arm,  from  which  two  iron 
strips  on  the  inner  and  outer  sides 
connect  at  the  elbow  in  an  adjusta- 
ble hinge-joint  that  may  be  fastened 
at  any  angle.  Instead  of  adjusting 
and  fastening  the  hinge-joint,  the 
forearm  may  be  flexed  by  means  of 
elastic  bands  attached  to  the  two 
sheaths.  Fitted  with  such  an  ap- 
paratus, the  forearm  can  move  only 
in  a  certain  plane.  The  slight  de- 
gree of  active  motion  possible  at 
first  is  rapidly  increased  by  exer- 
cising; the  muscles.  The  ends  of 
the  bones  by  their  constant  contact 
gradually  conform  to  each  other  ; 
connective  tissue  forms  between 
them  and  binds  them  more  and 
more  stably  together.  In  a  short 
time  a  firm  and  natural  stability  is 
acquired,  so  that  the  apparatus  is 
superfluous  and  required  only  dur- 
ing heavy  labor.  In  Kocher 's  ex- 
perience the  patient  was  not  infrequently  able  to  do  heavy  work  later 
without  the  apparatus.  One  can  understand  this  from  the  or-ray  pictures 
of  Kocher's  cases,  reproduced  by  Oschmann;  in  25  cases  of  total  resec- 
tion, 36  per  cent,  were  able  to  do  light  work,  64  per  cent,  hard  work. 
The  prevention  of  a  loose  joint  may  be  nullified  by  beginning  passive 
Vol.  III.— 15 


Apparatus  for  lex  -  .  i  following 

I  ion. 


226  OPERATIONS  ON  THE  ELBOW-JOINT. 

motion  too  early.  In  the  event  of  a  passively  or,  what  is  more  unpleasant, 
an  actively  loose  joint  forming,  the  hand  may  be  fairly  fitted  for  light  work 
by  applying  a  permanent  strip  splint,  such  as  the  one  designed  by  Socin, 
Bidder,  and  others.  Fig.  147  is  an  illustration  of  a  splint  of  this  sort; 
the  two  sheaths  encircling  the  forearm  and  upper  arm  are  hinged  at  the 
elbow  by  means  of  the  two  iron  strips,  and  can  be  held  at  any  angle  by 
tightening  a  nut  at  the  joint.  Ankylosis  is  quite  as  undesirable  as  a 
loose  joint;  often,  however,  it  cannot  be  prevented.  If  the  arm  becomes 
fixed  in  semiflexion,  the  advisability  of  further  operation  is  open  to 
question.  The  possibility  of  a  loose  joint  resulting  from  the  second  opera- 
tion and  the  consequent  decreased  usefulness  of  the  arm  can  never  be 
prevented  with  certainty.  If  the  patient  is  compelled  to  do  hard  work, 
the  surgeon  is  always  justified  in  discouraging  a  second  operation. 

The  question  of  resection  and  its  methods  has  been  discussed  in  the 
foregoing  chiefly  with  reference  to  tuberculosis,  which  is  by  far  the  most 
frequent  indication  for  operation.  The  technic  and  treatment  are  appli- 
cable to  all  resections  carried  out  for  other  purposes.  In  resecting  for 
an  irreducible  dislocation,  v.  Brims  suggests  the  use  of  Huter's  bilateral 
incision;  in  like  manner  one  may  use  this  or  that  method  of  resection 
for  a  purulent  inflammation  of  the  joint.  Injuries  will  demand  an 
incision  appropriate  to  the  lesion,  so  that  details  are  superfluous.  Know- 
ing the  above-mentioned  methods  for  total  resection,  it  is  easy  to  select 
and  modify  a  method  for  partial  resection.  The  value  of  partial  resec- 
tion for  tuberculosis  of  the  elbow,  taking  into  account  the  frequency 
of  the  primary  osseous  form,  has  already  been  emphasized;  it  is  ad- 
visable to  use  one  of  the  incisions  recommended  for  total  resection  to 
obtain  a  free  view  of  the  joint  and  remove  all  diseased  tissue.  For 
minor  operations— synovectomy,  arthrectomy — inspection  of  the  joint 
makes  incision  unavoidable.  For  such  inspection  Tiling  makes  a 
curved  incision,  beginning  at  the  radiohumeral  articulation  and  carried 
in  a  curve  upward  above  the  olecranon  so  that  the  triceps  is  divided  in 
its  muscular  portion.  The  incision  ends  below  the  joint-line  of  the 
humerus  and  ulna.  The  stump  of  the  triceps  is  turned  back  and  drawn 
downward ;  the  ulnar  nerve  is  drawn  out  and  retracted  to  the  inner  side ; 
the  epicondyle  is  chiselled  off  and  the  joint  opened.  In  this  manner  the 
joint  can  be  viewed  throughout.  The  capsule  and  synovialis  are  excised. 
The  epicondyle  is  sutured  back  in  place  and  the  triceps  reunited.  Early 
motion  is  necessary  to  prevent  ankylosis.  Naturally  by  this  incision 
one  may  perform  any  degree  of  partial  resection. 


AMPUTATION  AT  THE  ELBOW-JOINT. 

Where  amputation  is  necessary  for  severe  injuries  of  the  forearm, 
it  is  preferable  when  possible  to  resect  below  the  elbow-joint,  leaving 
the  attachments  of  the  triceps  and  biceps  intact,  as  the  short  stump 
thus  obtained  gives  much  better  results.  Amputation  of  the  elbow 
may  be  necessary,  however,  in  cases  of  complete  destruction  or  severe 


LIGATION  OF  THE  CUBITAL  ARTERY.  227 

injuries  of  the  forearm,  such  as  are  common  in  the  mechanical  industries; 
also  for  extensive  injury  of  the  soft  parts  with  more  or  less  complete 
exposure  of  the  hones  of  the  forearm.  Such  extensive  defects  of  the 
skin  and  soft  parts  may  be  covered  in  with  Thiersch  grafts  or  skin-flaps 
from  the  chest  or  abdomen;  even  here  conservative  surgery  has  its 
limitations,  however.  The  preservation  or  amputation  of  the  arm  will 
depend  upon  the  amount  of  damage  to  the  vessels.  In  cases  in  which 
it  is  doubtful  whether  gangrene  will  occur  or  not,  the  operation  may  lie 
deferred  until  gangrene  is  evident.  Old  and  feeble  individuals  should 
not  be  subjected  to  severe  and  long  suppuration;  amputation  should 
be  early.  It  is  often  indicated  in  septic  processes,  especially  in  the 
malignant  form  of  diabetic  gangrene,  and  in  the  latter  instance  should 
be  done  at  once  if  the  process  appears  to  be  progressive  with  high  fever. 
Tn  diabetic  phlegmon,  in  which  diffuse  oedema  often  spreads  rapidly  up 
the  arm,  one  can  operate  in  the  ©edematous  area  without  fearing  advance 
of  the  process  in  the  oedematous  stump,  for  the  oedema  precedes  the 
bacterial  invasion  in  the  cellular  spaces,  as  has  been  demonstrated  by 
cultures.  In  the  classical  method  of  amputation  the  anterior  flap  is 
quadrilateral  with  base  about  an  inch  below  the  epicondyles;  this  quad- 
rate form  is  essential  to  cover  in  the  broad  projecting  cubital  process. 
The  posterior  incision  is  semicircular;  the  anterior  flap  is  dissected  off 
upward  to  the  bone  and  retracted  until  the  capsule  is  exposed.  The 
joint  is  then  incised,  beginning  at  the  head  of  the  radius,  and  the 
lateral  ligaments  divided;  the  forearm  is  hyperextended,  the  attachment 
of  the  triceps  divided,  and  the  dissection  of  the  posterior  flap  completed; 
the  cubital  artery,  or  the  radial  and  ulnar  if  the  branching  was  higher 
up,  and  the  branches  of  the  rete  articulare  are  ligated. 

Instead  of  the  anterior  flap  incision,  one  may  use  the  circular  incision 
with  a  cuff  dissection  of  the  skin  to  the  level  of  the  joint.  Many  advise 
removal  of  the  cubital  process,  partly  on  account  of  the  smaller  covering 
required,  partly  for  the  removal  of  the  synovialis;  this  is  not  necessary. 
The  preservation  of  the  cubital  process  is  important  for  the  application 
and  stability  of  a  prothesis. 


LIGATION  OF  THE  CUBITAL  ARTERY  AND  LOCATION  OF  THE 
NERVES  AT   THE  ELBOW-JOINT. 

To  ligate  the  cubital  artery,  locate  first  the  cephalic,  basilic,  and 
median  veins  of  the  venous  plexus;  the  cephalic  vein  runs  on  the  outer 
side  (the  radial  side)  of  the  arm;  the  basilic  vein  on  the  ulnar;  and  the 
main  branch  of  the  median  joins  the  two.  A  longitudinal  incision  is 
made  in  the  elbow  from  \  to  -V  inch  to  the  inner  side  of  the  biceps  tendon. 
The  median  vein  crossed  by  the  incision  is  retracted;  beneath  the  skin 
lies  the  semilunar  fascia,  running  obliquely  from  the  biceps  tendon 
to  the  outer  border  of  the  fascia  of  the  forearm ;  directly  beneath  it  lies 
the  artery  with  its  two  small  veins;  the  artery  lies  therefore  between  the 
biceps  tendon  on  the  outer  side  and  the  median  nerve  on  the  inner  side. 


228  OPERATIONS  ON  THE  ELBOW-JOINT 

If  the  brachial  artery  divides  higher  up  on  the  forearm  than  normally, 
the  ulnar  artery  may  lie  upon  the  semilunar  fascia;  or  twin  arteries  may 
be  found  beneath  the  fascia. 

The  median  nerve  is  easily  found  at  the  outer  edge  of  the  pronator 
radii  teres  and  to  the  ulnar  side  of  the  cubital  artery.  The  ulnar  nerve 
lies  superficially  behind  the  internal  condyle,  palpable  through  the  skin 
with  the  arm  extended,  as  a  thick  round  cord,  and  is  not  easily  over- 
looked. The  radial  nerve,  often  damaged  or  torn  in  the  same  manner 
as  the  preceding  nerves  by  trauma,  such  as  fractures  and  dislocations 
of  the  elbow,  is  more  difficult  to  expose.  The  incision  should  be  made 
along  the  inner  border  of  the  supinator  longus;  the  cephalic  vein  is 
pushed  aside;  on  separating  the  fascia  on  the  outer  side  of  the  biceps 
tendon  the  musculocutaneous  nerve  is  exposed.  The  radial  nerve  lies 
beneath  the  supinator  longus,  which  is  retracted,  and  divides  into  a 
superficial  and  a  deep  branch  at  the  outer  side  of  the  brachialis  anticus. 
In  opening  the  joint  for  drainage  or  operations  at  the  head  of  the  radius, 
one  should  always  know  the  exact  position  of  the  nerves. 


CHAPTER   XI  I. 

MALFORMATIONS,  INJURIES,  AND   DISEASES  OF  THE  SKIN  AND 
SOFT  PARTS  OF  THE  ELBOW  AND  FOREARM. 

The  so-called  "wing-skin"  formation  is  apparently  very  rare  at  the 
elbow.  The  author  found  only  1  case  in  the  literature.  The  patient 
illustrated  by  Fig.  14S  had  a  symmetrical  wing  formation  of  the  skin 
at  the  elbows,  preventing  extension  beyond  a  right  angle;  flexion  was 

Fig.  148. 


"  Wing-skin"  formation  at  the  elbow.    Man  aged  thirty  years. 

free;  beneath  the  skin  could  be  felt  a  tense  thin  fascia.  Muscular  defects 
are  combined  with  this  formation;  the  lower  half  of  the  biceps  and 
triceps  is  lacking.  These  muscular  defects  and  the  shortening  of  the 
fascia,  producing  wing-skin,  are  apparently  referable  to  the  same 
unknown  cause.  A  child  of  the  patient  had  the  same  peculiarity  in  both 
elbows,  although  not  so  markedly  developed.  This  heredity  apparently 
speaks  against  a  conceivable  purely  mechanical  cause — intrauterine 
pressure  or  adhesions. 


INJURIES  AND  DISEASES  OF  THE  SKIN  OF  THE  ELBOW  AND 

FOREARM. 

Skin- wounds  on  the  forearm,  such  as  cuts,  tears,  bites,  and  contusions, 
are  not  without  danger  on  account  of  the  easy  transmission  of  infection 
in  and  between  the  muscular  interspaces,  and  therefore  require  careful 

(  229  ) 


230    MALFORMATIONS  AND  DISEASES  OF  ELBOW  AND  FOREARM. 

antiseptic  and  aseptic  treatment;  the  edges  of  the  wound  should  be 
excised  and  dirt  and  foreign  bodies,  such  as  fragments  of  glass,  wood, 
etc.,  removed.  In  an  exposed  area  like  the  elbow  and  forearm,  injuries 
producing  extensive  defects  in  the  skin  are  frequent.  In  the  modern 
mechanical  industries,  in  which  the  various  kinds  of  machinery  are  con- 
trolled by  hand,  severe  lesions  of  the  skin  and  arm  are  not  uncommon; 
the  skin  of  the  forearm  is  in  some  instances  torn  off  like  a  cuff  up  to 
the  elbow.  Transmission  appliances  also,  such  as  gearing  and  belting, 
are  apt  to  produce  such  lesions.  Burns  often  result  in  extensive  destruc- 
tion of  the  skin.  Recent  wounds  with  more  or  less  destruction  of  the 
skin,  if  they  are  not  badly  soiled,  may  be  covered  immediately  with 
Thiersch  grafts;  the  author  has  always  seen  excellent  results,  and  not 
infrequently  large  surfaces  completely  covered  in  a  short  time,  in  from 
two  to  three  weeks.  Secondary  defects,  as  from  burns,  heal  quickly  by 
grafting. 

The  Thiersch  method,  as  employed  in  the  Leipzig  clinic,  the  place 
of  its  discovery  and  development,  is  as  follows:  if  the  area  to  be  treated 
is  a  defect  following  injury  or  a  granulating  surface  from  a  burn,  the 
author  waits  until  the  discharge  and  suppuration  have  ceased  and  the 
granulations  appear  active  and  healthy.  If  the  granulations  are  spongy, 
soft,  and  exuberant,  the  pure  silver  nitrate  stick  is  applied  two  or  three 
times  a  week;  if  healthy,  the  surface  of  the  granulation  is  cut  off  smoothly 
with  a  thin  knife,  or,  better,  scraped  down  to  the  superficial  fascia  with 
a  sharp  spoon.  Bleeding  is  checked  by  gauze  pads  and  the  grafts  pre- 
pared from  the  thigh  with  a  razor.     The  grafts  are  applied  upon  the 

Fig.  149. 


Large  skin  defect  due  to  spinning  machine  accident.     iSclireiber.) 

wound  and  covered  with  silk,  or,  perhaps  better,  with  tin-foil,  and  band- 
aged with  gauze.  In  four  or  five  days,  or  later  if  the  discharge  is  slight, 
the  first  dressing  is  changed  and  a  new  one  applied.  In  about  ten  days 
the  wound  is  dressed  with  dry  gauze  or  ointment  (zinc  ointment,  etc.). 
In  this  manner  large  areas  can  be  covered  in  a  short  time;  subsequent 
contraction  is  usually  slight.  The  accompanving  illustrations  (Fig.  140 
and  Fig.  150)  show  the  excellent  results  of  the  Thiersch  method,  espe- 
cially the  surprisingly  slight  contracture  at  the  elbow,  and  the  almost 
complete  extensibility  of    the  fingers,  in  spite  of    the  fact  that  in  this 


ISJURIES  AM)  DISEASES  OF  SKIS  OF  ELBO  \Y  AM)  FOREARM.     231 

injury  almost  the  entire  inner  side  of  the  arm  and  upper  arm  were  skinned 
and  had  to  be  covered  in.  Slight  oozing  of  Mood  or  much  discharge 
from  the  scraped  surface  of  the  fascia  sometimes  prevents  the  grafts 
from  taking.  It  is  certain  that  the  surface  is  irritated  by  the  curettage 
and  the  discharge  increased.  To  avoid  the  injurious  effect  of  this  dis- 
charge, the  author  has  waited  twenty-four  or  forty-eight  hours  after  scrap- 
ing before  applying  the  grafts,  and  has  been  pleased  with  the  result. 

Fig.   150. 


Fig.  149,  cured  by  Thiersch  skin-grafting. 


The  plastic-flap  method  is  in  the  author's  experience  less  advisable  and 
more  complicated  than  the  Thiersch  method.  One  may  follow  Krause's 
advice  and  use  flaps  from  other  parts  of  the  body  from  which  the  subcu- 
taneous fat  has  been  removed;  these  are  adapted  more  for  the  leg  and 


Fig.  151. 


Cicatricial  contraction  of  skin  and  contracture  of  elbow. 


foot  than  for  the  upper  extremity.  They  are  valuable,  however,  for 
places  such  as  the  olecranon,  exposed  to  external  injury,  and  in  which 
the  Thiersch  grafts  are  frequently  found  too  delicate.  The  bridge-flap 
method  consists  in  freeing  a  bridge  of  skin  on  the  abdomen  or  thorax 
corresponding  to  the  level  of  the  forearm  and  pushing  the  forearm 
beneath  it;  the  arm  is  bandaged  in  position  and  held  for  two  to  three 


232     MALFOBMA  TIONS  AND  DISEASES  OF  ELBOW  AND  FOREARM. 

weeks;  the  attachments  of  the  flap  are  then  divided.  Cicatricial  con- 
tractures are  often  unavoidable  in  case  of  extensive  defects,  even  though 
the  large  areas  can  be  covered  in  by  flaps  or  grafts.  Such  contractures, 
according  to  their  position,  may  produce  very  peculiar  postures  of  the 
hand  and  forearm;  Fig.  151  shows  a  cicatricial  contracture  at  the  elbow 
from  a  burn;  extension  was  limited  to  100  degrees.  By  transverse 
incision  and  transplantation  extension  was  increased  to  160  degrees; 
flexion  was  free. 

In  order  to  overcome  such  contractures  as  far  as  possible  operation 
is  unavoidable.  Gymnastic  exercises  may  gradually  produce  improve- 
ment by  stretching  the  cicatrix;  nevertheless  transverse  incisions  with 
forcible  extension  under  anaesthesia  and  subsequent  grafting  are  usually 
necessary.  The  incisions  are  modified  naturally  according  to  the  direc- 
tion and  extent  of  the  cicatrix;  and  their  effect  can  be  heightened  by 
implanting  pedunculated  flaps  from  the  upper  arm.  Continuous  exten- 
sion of  the  forearm,  as  advised  by  Schede,  may  also  effect  gradual 
stretching  of  the  contracture;  adhesive-plaster  strips  are  applied  to  the 
front  and  back  of  the  forearm  and  weights  attached;  by  the  continuous 
traction  the  skin  of  the  upper  arm  is  drawn  down  and  its  mobility  and 
extensibility  may  be  utilized  for  covering  in  the  elbow.  Such  contrac- 
tures require  protracted  after-treatment  to  prevent  recurrence. 

Inflammation  and  phlegmon  often  follow  injuries  of  the  forearm,  but 
are  more  frequently  transmitted  from  inflammation  in  the  fingers,  chiefly 
panaritium.  In  simple  lymphangitis  the  red  streaks  of  the  lymphatics 
appear  on  the  flexor  surface,  accompanied  by  secondary  swelling  and 
tenderness  of  the  cubital  and  axillary  glands;  -the  process  subsides 
rapidly  with  rest  and  the  application  of  wet  dressings;  Volkmann's 
suspension  splint  is  very  useful,  the  arm  being  elevated  in  the  trough 
in  the  usual  manner.  Timely  incision,  drainage,  and  elevation  of  the 
arm  are  necessary  for  subcutaneous  and  deeper  phlegmonous  inflam- 
mations, either  from  a  panaritium  or  from  wounds  of  the  forearm,  to 
prevent  the  suppuration  from  advancing.  If  the  inflammation  extends 
to  the  joint,  as  happens  infrequently,  free  drainage  is  indicated.  Phleg- 
mon and  secondary  arthritis  following  acute  osteomyelitis  of  the  forearm 
will  be  considered  later.  As  lymphangitis  shows  a  tendency  to  follow 
the  vessels,  especially  the  cutaneous  veins,  in  certain  cases  of  severe 
infection  one  finds  extensive  thrombosis,  chiefly  of  the  superficial  veins, 
the  veins  apparently  containing  purulent  thrombi.  The  clinical  picture 
of  a  pyiemia  beginning  with  chills  points  to  the  vascular  system  as  the 
source  of  infection  in  these  cases  of  purulent  thrombosis.  Founding  his 
hopes  upon  the  good  results  obtained  by  ligation  of  the  jugular  vein  in 
thrombosis  of  the  lateral  sinus,  Trendelenburg  sought  in  one  case  to 
wall  off  the  source  of  the  pyamiie  infection  by  extirpating  the  thrombosed 
superficial  veins,  but  the  general  infection  had  already  advanced  too  far; 
the  patient  died.  Miiller  has  recently  operated  upon  such  cases  with 
success. 

The  author  will  mention  here  only  a  few  of  the  inflammatory  diseases 
of  the  skin  of  the  forearm  and  elbow  which  concern  the  surgeon.    The 


DISEASES  OF  TENDOX  SHEATHS  OF  ELBOW  AND  FOREARM.     233 

true  skin  affections,  such  as  psoriasis,  herpes  tonsurans,  etc.,  do  not 
belong  in  this  text-book.  Occasionally  anthrax,  which  the  author  has 
opportunity  to  observe  so  often,  is  seen  upon  the  forearm,  especially  in 

cattlemen:  at  the  Leipzig  clinic  a  butcher  appeared  who,  after  skinning 
an  animal  which  had  died  of  anthrax,  had  about  twenty  pustules  <>n 
both  arms;  deep  cauterization  with  the  Paquelin  cautery  effected  a  cure. 
Of  further  interest  to  the  surgeon  is  the  infrequent  occurrence  of  carci- 
noma on  the  forearm,  as  reported  by  Volkmann  and  others  in  the  case 
of  paraffin-workers,  who  often  have  chronic  eczema  on  the  forearm.  The 
interrelationship  of  this  carcinoma  and  the  eczema,  and  indirectly  of  the 
occupation  of  distilling  certain  animal  products,  still  requires  explana- 
tion. 


INJURIES    AND    DISEASES    OF    THE    TENDON-SHEATHS    AND 
SYNOVIAL  SACS  OF  THE  ELBOW  AND  FOREARM. 

Tendons  severed  by  wounds  of  the  lower  part  of  the  forearm  must 
be  sutured;  the  suture  methods  will  be  considered  more  in  detail  in  the 
chapter  on  Injuries  of  the  Hand.  It  is  self-evident  that  the  disinfection 
and  cleansing  of  wounds,  particularly  of  the  tendons,  in  this  region  must 
be  strictly  enforced,  as  union  of  sutured  tendons  requires  complete 
asepsis.  If  suppuration  occurs,  the  sutures  break  and  the  stumps  of  the 
tendons  retract  or  become  necrotic  and  slough.  Secondary  adhesions 
between  the  tendons  and  the  adjacent  structures  following  a  purulent 
inflammation  may  be  so  firm  as  to  be  inseparable  even  by  long-continued 
energetic  mechanical  treatment.  The  location  and  suture  of  the  corre- 
sponding stumps  naturally  presuppose  an  exact  knowledge  of  the 
anatomy.  If  the  proximal  stumps  are  strongly  retracted,  they  must  be 
sought  through  a  longitudinal  incision;  bandaging  the  forearm  from  the 
elbow  down  with  an  elastic  bandage  is  useful  in  pushing  down  the 
proximal  ends  into  the  wound.  The  peripheral  ends  are  forced  into  the 
wound  by  flexing  or  hyperextending  the  hand,  according  as  the  flexor 
or  extensor  tendons  are  involved.  As  sutures  the  author  uses  only  silk. 
At  the  end  of  ten  or  at  the  most  fourteen  days'  fixation  in  the  position 
affording  the  greatest  relaxation  of  the  sutured  tendons,  active  and 
passive  motion  are  begun  gradually  to  prevent  adhesion  of  the  tendon 
at  the  point  of  suture  to  the  adjacent  tissues,  and  as  far  as  possible  to 
restore  the  normal  mobility  of  the  hand  and  fingers. 

The  subject  of  inflammation  of  the  tendon-sheaths,  so  important  for 
the  surgeon,  is  merely  touched  upon  at  this  point,  as  tenosynovitis  will 
be  considered  in  detail  in  the  chapter  on  the  Hand,  for  most  of  the  cases 
of  inflammation  of  the  tendon-sheaths  are  by  transmission  from  the 
hand  and  wrist.  The  loose  thin  sheaths  containing  the  tendons  of  the 
forearm  allow  the  inflammation  to  spread  diffusely  in  the  forearm  and 
penetrate  into  the  muscular  interspaces.  The  prevention  of  this  deep 
inflammation  of  the  forearm  demands  sufficient  and  timely  incision  and 
drainage.     Tenosynovitis  crepitans,  or  sicca,  is  an  inflammation  with 


234    MALFOBMA  TIONS  AND  DISEASES  OF  ELB  0  W  AND  FOREARM. 

peculiarly  characteristic  symptoms  and  involves  by  choice  the  tendons 
of  the  forearm;  the  tendon-sheath  deposits  fibrin  on  its  inner  surface; 
movements  of  the  fingers  and  hand  are  painful;  the  hand  laid  upon  the 
tender  spot  feels  a  friction-crepitus,  like  crackling  leather,  which,  heard 
with  the  stethoscope,  sounds  like  the  rale  of  dry  pleurisy;  it  is  caused 
usually  by  overexertion,  especially  by  unaccustomed  handwork.  The 
tendons  upon  the  posterior  surface  of  the  forearm,  particularly  the  exten- 
sors of  the  thumb,  are  the  ones  more  commonly  affected,  and  of  these 
the  abductor  pollicis  and  extensor  pollicis  brevis  with  surprising  fre- 
quency. The  inflammation  subsides  in  a  short  time  with  rest  and  com- 
pression by  means  of  wet  dressings. 

Inflammation  of  the  synovial  sacs  of  the  elbow  affects  chiefly  the 
olecranon  bursa  and  the  bursa  beneath  the  biceps  tendon  on  the  tuber- 
osity of  the  radius.  Other  bursa?  in  this  region  are  small  and  not  con- 
stant. Bursitis  olecrani  may  occur  as  an  acute  inflammation  following 
injury,  and  is  characterized  by  a  circumscribed  painful  and  reddened 
swelling  on  the  posterior  surface  of  the  olecranon;  the  sharp  demarcation 
of  the  swelling  at  this  point,  the  pain,  the  non-involvement  of  the  joint 
recognizable  by  the  existence  of  its  normal  mobility,  signify  disease  of 
the  bursa.  Milder  inflammations  subside  under  wet  dressings;  puru- 
lent forms  demand  incision  and  drainage  or  the  excision  of  the  bursa. 
The  discharge  of  mucoserous  fluid  from  a  bursa  opened  by  trauma  may 
be  mistaken  for  an  injury  of  the  joint. 

Hygroma,  the  chronic  form  of  bursitis,  occurs  as  an  occupation- 
disease  at  the  olecranon  as  in  many  other  parts  of  the  body;  it  usually 
affects  miners  working  in  pits,  tanners,  or  coopers,  in  whom,  from  the 
nature  of  their  work,  the  olecranon  is  exposed  to  frequent  irritation. 
It  is  best  to  excise  the  bursa  and  obviate  the  recurrence  which  is  apt  to 
take  place  after  simple  incision.  The  bursa  may  become  tuberculous 
exceptionally  or,  when  associated  with  gout,  be  the  seat  of  uric-acid  de- 
posits. In  both  instances  it  should  be  excised.  Hematoma  resulting 
from  trauma  is  evidenced  by  an  elastic  tumor  with  the  springy  resistance 
of  a  rubber  ball;  it  usually  subsides  spontaneously.  Exceptionally  one 
finds  a  small  bursa  beneath  the  triceps  tendon,  but  it  has  no  more  signifi- 
cance than  those  occurring  upon  the  epicondyles.  The  bursa  lying  deep 
beneath  the  biceps  insertion  upon  the  tuberosity  of  the  radius  is  usually 
small ;  it  is  hard  to  verify  a  diseased  condition  on  account  of  its  deep  situa- 
tion. Sudden  contraction  of  the  biceps  may  cause  hemorrhage  in  the 
bursa,  evidenced  by  an  elastic  fulness  and  swelling  of  the  sac;  pain  at 
that  point  on  the  radius,  slight  functional  disturbance,  and  sensitiveness 
on  rotation,  signify  disease  or  injury  of  the  bursa. 


INJURIES  AND  DISEASES   OF  THE   VESSELS   OF  THE  ELBOW 

AND  FOREARM. 

The  cubital,  ulnar,  and  radial  arteries  are  usually  sought  and  ligated 
at  the  point  of  injury  in  trauma  of  this  area;  ligation  at  a  point  of  choice 


DISEASES  OF  VESSELS  OF  ELBOW  AND  FOREARM.         235 

proximal  to  the  site  of  injury  is  required  only  exceptionally.  Formerly 
the  more  general  employmenl  of  phlebotomy  with  the  arterial  lance 
exposed  the  cubital  artery  to  frequent  injury;  if  in  opening  the  median 
vein  the  fleam  struck  the  cubital  artery  at  the  same  time,  it  led  occa- 
sionally to  the  formation  of  an  arteriovenous  aneurism,  a  sacculated 
cavity  communicating  with  the  median  vein  and  the  cubital  artery. 
Venesection,  formerly  so  frequently  used  and  regarded  as  possessing  a 
life-saving  power  even  in  the  most  diverse  general  diseases,  particularly 
the  infectious  diseases,  is  little  employed  at  the  present  time.  With  tin- 
modern  technic  of  incision  with  scalpel  and  forceps,  damage  to  the 
cubital  artery  is  scarcely  known;  the  operation  is  facilitated  by  slightly 
constricting  the  upper  arm  until  the  venous  current  is  checked,  the 
arterial  flow  being  undisturbed;  the  vein,  easily  seen  beneath  the  skin, 
is  then  opened  under  local  anaesthesia  and  the  flow  of  blood  allowed  or 
checked,  as  desired.  In  adults  500  c.c.  or  more  may  be  withdrawn 
without  danger;  if  the  flow  is  hindered  by  clotting,  slight  movements 
will  stimulate  the  circulation;  suture  is  usually  unnecessary.  After 
removing  the  constriction  immobilization  in  a  simple  dressing  checks 
the  flow.     Naturally  the  operation  must  be  aseptic. 

Arteriovenous  aneurism  or  aneurismal  varix  is,  as  related,  a  sac 
communicating  with  the  median  vein  and  cubital  artery  to  which  the 
pulsation  of  the  artery  is  communicated.  The  diagnosis  of  this  formerly 
not  infrequent  disease  is  not  difficult;  the  same  applies  to  the  treatment, 
which  consists  in  the  excision  of  the  sac  and  double  ligation  of  the  artery 
and  vein.  Aneurism  of  the  arteries  is  rare  in  the  forearm.  The  veins 
of  the  elbow  are  of  interest  on  account  of  their  being  frequently  incised  for 
the  infusion  of  salt  solution.  The  most  useful  and  more  advisable  method, 
namely,  of  subcutaneous  injection,  will  only  be  replaced  exceptionally 
by  infusion  into  the  vein  in  those  instances  in  which  it  is  necessary  to 
inject  a  large  amount  of  0.9  per  cent,  salt  solution  rapidly  into  the 
body. 

On  account  of  its  superficial  and  accessible  position  the  median  vein  is 
well  adapted  for  infusion  as  used  after  severe  hemorrhage;  a  fine  canula 
is  introduced  into  the  vein  and  the  solution  allowed  to  flow  slowly  and 
guardedlv  under  slight  pressure.  The  temperature  should  be  between 
39°  and  40°  C.  [100°  to  115°  F.]. 

Diffuse  dilatation  of  the  vessels,  a  disease  of  the  vascular  system  of 
the  forearm,  has  been  described  by  a  few  authors,  but  its  etiology  and 
nature  are  still  unexplained;  it  is  apparently  an  aneurismal  dilatation 
of  the  arteries  and  veins;  arterial  pulsation  may  be  transmitted  directly 
through  the  widened  capillaries  to  the  veins.  If  the  deep  vessels  are 
much  involved,  the  angiomatous  formation  may  extend  through  the 
entire  arm,  as  observed  in  the  case  of  Andry's  and  of  the  author's.  In 
Andry's  case  there  were  motor,  sensory,  and  vasomotor  disturbances  in 
the  arm.  The  disease  dated  from  early  youth,  possibly  congenital;  the 
arm  when  amputated  showed  the  muscles,  nerves,  and  even  the  bones 
changed  by  the  angioma.  In  the  author's  case  the  radius  was  similarly 
dilated  as  bv  a  diffuse  tumor. 


236     MALFORMATIONS  AND  DISEASES  OF  ELBO  W  AND  FOREARM. 

INJURIES  AND   DISEASES   OF   THE  NERVES   OF  THE  ELBOW  AND 
FOREARM.     TENDON-TRANSPLANTATION. 


Fig.  152. 


In  the  section  on  Fractures  and  Dislocations  the  author  has  frequently 
referred  to  the  lesions  of  the  nerves  produced  by  displacement  of  frag- 
ments or  by  direct  trauma.  In  supracondyloid  fracture  and  T-  and 
Y-shaped  fractures  of  the  lower  end  of  the  humerus,  the  median  nerve 
is  occasionally  crushed  or  torn  at  the  elbow;  in  fracture  of  the  head  of 
the  radius  and  the  external  condyle  the  radial  nerve  may  be  involved; 
in  injuries  of  the  internal  condyle  and  epicondyle  the  ulnar  nerve  may 
suffer.  By  incised  or  puncture- wounds  or  extensive  laceration  of  the 
soft  parts,  the  nerves  may  be  divided  at  many  points.  The  frequency 
of  such  injuries  is  governed  by  the  amount  of  protection  afforded  the 
nerve  by  its  situation;  for  example,  the  superficial  position  of  the  ulnar 
nerve  in  the  groove  behind  the  internal  epicondyle  is  the  reason  for  the 
frequent  injury  of  the  nerve  at  that  point.  The  symptoms  of  paralysis 
are  complete  or  incomplete,  according  as  the  nerve  is  completely 
lacerated  and  divided  or  only  slightly  contused. 

Injuries  of  the  Radial  Nerve. — The  motor  fibres  of  the  radial  nerve 
supply  the  extensors  of  the  hand,  the  supinator  brevis  and  longus,  the 

extensors  of  the  first  phalanges  of  all  the 
fingers,  and  the  extensor  of  the  terminal 
phalanx  of  the  thumb.  In  paralysis  of  the 
radial  nerve  the  hand  is  pronated,  hangs 
limp,  and  cannot  be  raised;  the  fingers  can- 
not be  extended;  if  the  first  phalanges  are 
held  extended,  the  patient  is  able  to  extend 
the  second  and  third  phalanges  (ulnar  nerve 
innervation).  On  account  of  the  drooping 
of  the  hand  the  flexors  supplied  by  the  me- 
dian nerve  are  impaired,  so  the  condition 
simulates  weakness  in  the  region  of  this 
nerve;  this  apparent  paralysis  is  overcome 
by  extending  the  hand  of  the  patient.  Ab- 
duction and  adduction  of  the  hand  are  also 
impaired.  The  sensory  disturbances  follow- 
ing injury  of  the  radial  nerve  are  not  so  con- 
stant as  the  motor;  it  has  been  proved  in 
numerous  instances  that  the  disturbance  of 
sensibility  in  the  skin  area  supplied  by  the 
radial  may  be  slight  or  absent  even  after 
complete  division  of  the  nerve,  as  conduc- 
tion is  immediately  restored  through  anastomosis  with  the  ulnar  or 
median  ;  exceptionally  this  vicarious  conduction  begins  immediately  ; 
sometimes  the  disturbance  is  not  compensated  for  several  days.  If  the 
compensation  is  absent  for  a  longer  period,  one  can  often  demonstrate 
a  gradual  diminution  in  size  of  the  anaesthetic  area,  sensibility  returning 
slowly  from  the  periphery.    The  zone  farthest  removed  from  the  region 


External  cutaneous 

nerve. 


Area  supplied  by  the  radial  nerve  on 
the  outer  side  of  the  hand. 


DISEASES  OF  NERVES  OF  ELBOW  AND  FOREARM.  237 

of  the  ulnar  and  median,  and  so  most  difficult  to  supply,  remains  insen- 
sible for  the  longesl  time;  this  is  the  region  upon  the  dorsum  of  the 
hand  between  the  first  and  second  metacarpals,  indicated  in  Fig-.  152 
by  the  cross-lines. 

The  radial  nerve  divides  in  front  of  the  external  condyle  into  a  deep 
and  a  superficial  branch;  the  deep  branch  perforates  the  supinator 
brevis,  passes  around  the  neck  of  the  radius,  supplies  the  extensor  mus- 
cles of  the  forearm,  and  sends  the  posterior  interosseous  as  far  as  the 
capsule  of  the  wrist-joint.  The  superficial  branch  approaches  the  radial 
artery  below  the  elbow,  covered  by  the  supinator  longus,  courses  along 
the  outer  side  of  the  forearm  to  the  wrist,  and  there  supplies  the  skin  on 
the  dorsal  side  of  the  hand  in  the  area  indicated  in  Fig.  152. 

The  degree  of  disturbance  varies  according  to  the  involvement  of  the 
radial  nerve  as  a  whole  at  the  elbow-joint,  or  only  in  one  of  its  branches 
in  the  forearm;  lesions  of  the  deep  branch  produce  paralysis  of  the 
extensor  muscles  of  the  forearm;  lesions  of  the  superficial  branch,  more 
or  less  complete  anaesthesia  of  the  area  indicated.  Suture  of  the  radial 
nerve  (musculospiral)  in  the  upper  arm  is  very  simple,  as  it  has  consid- 
erable solidity  at  that  point;  suture  of  the  branches  beyond  its  division 
is  more  difficult;  in  the  lower  half  of  the  forearm  suture  is  no  longer 
necessary,  as  the  nerve  after  giving  off  its  muscular  branches  at  that 
point  has  no  important  function  to  fulfil. 

If  the  restoration  of  conduction  is  impossible  or  not  obtained  by 
suturing,  the  patient  may  be  benefited  by  an  apparatus  fixing  the  hand 
and  first  phalanges  and  artificially  flexing  and  extending  the  fingers. 
Among  others,  Heusner  describes  an  apparatus  consisting  of  a  sheath 
which,  on  the  flexor  surface  of  the  arm,  covers  an  iron  bracelet  and 
envelops  the  hand  and  forearm  to  the  fingers;  the  wrist  is  held  slightly 
extended;  the  metacarpal  joint  of  the  thumb  is  left  free;  upon  the  dorsal 
side  of  the  sheath  run  four  elastic  cords,  connecting  with  broad  elastic 
bands,  which  are  applied  like  cuffs  about  the  bases  of  the  proximal 
phalanges.  These  traction-bands  run  under  leather  covers  and  hold 
the  proximal  phalanges  extended.  The  hand  is  thus  capacitated  for 
light  work.  Even  a  simple  celluloid  sheath,  fixing  the  forearm  and  the 
hand  extended,  increases  the  usefulness  of  the  hand. 

Injuries  of  the  Median  Nerve. — The  injuries  most  frequently 
demanding  suture  of  the  median  nerve  are  incised  and  stab-wounds  on 
the  flexor  side  of  the  forearm  above  the  wrist. 

The  median  nerve  passes  down  the  arm  in  the  internal  bicipital 
groove  in  front  of  the  brachial  artery,  above  the  elbow  lying  to  the  inner 
side,  then  passes  beneath  the  pronator  teres  and  palmaris  longus  to 
the  middle  line  of  the  forearm,  whence  it  courses  between  the  palmaris 
magnus  and  flexor  sublimis  toward  the  hand,  passing  with  the  tendons 
of  the  fingers  beneath  the  transverse  ligament  of  the  wrist  to  the  palm. 
As  motor  nerve  it  supplies  all  the  muscles  on  the  flexor  surface  of  the 
forearm  except  the  flexor  carpi  ulnaris  and  a  part  of  the  flexor  pro- 
fundus, which  are  supplied  by  the  ulnar;  also  the  abductor  pollicis,  flexor 
brevis,  and  opponens  pollicis,  and  either  two  or  three  of  the  lumbricales. 


238     MALFORMA  TIONS  AND  DISEASES  OF  ELBO  W  AND  FOREARM. 

It  is  the  main  flexor  of  the  hand  and  fingers.  Only  a  small  part  of  the 
flexors  is  supplied  by  the  ulnar.  The  apposition  and  flexion  of  the 
thumb  and  the  pronation  of  the  hand  also  depend  on  the  median;  so  in 
lesions  of  the  nerve  full  flexion  of  the  hand  and  fingers  is  impaired,  the 
movements  of  the  thumb  are  severely  compromised;  as  the  adductor 
supplied  by  the  ulnar  is  the  only  active  muscle,  the  thumb  is  extended 
and  adducted,  lying  in  the  same  plane  with  the  other  fingers,  as  in 
the  so-called  "ape-hand."  The  sensory  disturbances  comprise  the  area 
indicated  in  Fig.  153;  the  extent  of  the  area  is  not  always  the  same. 

Injuries  of  the  Ulnar  Nerve.— Lesions  of  the  ulnar  nerve  produced 
by  the  same  forms  of  trauma  which  affect  the  median  are  not  infre- 
quent; the  site  of  injury  is  commonly  the  ulnar  groove  at  the  elbow, 
where  the  nerve  is  compressible  against  the  underlying  bone  and  exposed 
to  external  forces  by  its  superficial  position. 


Fig.  153. 


Fig.  154. 


a 


Area  supplied  by  the  median  nerve: 

a,  dorsum  ;   b,  palm. 


a  b 

Area  supplied  by  the  ulnar  nerve:  a,  dorsum;  b,  palm. 

The  nerve  runs  in  the  groove  between 
the  internal  epicondyle  and  the  olecranon, 
perforates  the  flexor  carpi  ulnaris,  and 
proceeds  between  this  and  the  flexor  pro- 
fundus at  the  inner  side  of  the  ulnar  artery 
to  the  wrist.  Above  the  wrist  it  divides  into 
a  volar  and  a  dorsal  branch;  the  latter  is 
the  sensory  nerve  for  the  back  of  the  hand. 
( Fig.  1 54. )  The  volar  branch  passes  over 
the  transverse  ligament  at  the  side  of  the 
pisiform  bone  to  the  palm  and  divides  into  a  superficial  and  deep  branch, 
the  former  supplying  the  skin,  the  latter  the  muscles  of  the  little  finger 
and  one  or  two  lumbricales,  the  volar  and  dorsal  interossei,  adductor 
pollicis,  and  deep  head  of  the  flexor  pollicis.  Ulnar  paralysis  is  mani- 
fested by  paralysis  of  the  interossei,  which  flex  the  proximal  phalanges 
and  extend  the  middle  and  terminal  phalanges  of  all  the  fingers  except 
the  thumb.  In  protracted  paralysis  the  action  of  the  unaffected  antago- 
nists produces  the  so-called  "claw-hand;"  the  proximal  phalanges  are 
hyperextended,  the  middle  and  terminal  phalanges  are  flexed.  The 
spreading  ability  of  the  fingers  produced  by  the  interossei  is  also  lost. 


diseases  <>r  xehves  or  ELBOW  AND  FOREARM.        239 

The  little  finger  cannol  be  apposed  to  tin-  thumb  opponens  minimi 
digiti;  or  abducted  abductor  minimi  digiti.  It  is  difficult  to  verify  loss 
of  adduction  of  the  thumb;  slight  weakness  of  flexion  of  the  hand 
depends  upon  paralysis  of  the  flexor  carpi  ulnaris. 

If  the  nerve  is  severed  by  a  Stab,  incised,  or  puncture  wound,  there 
is  no  question  as  to  suture  being  indicated.  If  the  paralysis  is  produced, 
however,  by  pressure,  as  by  injudicious  application  of  the  Esmarch  or  by 
compression  of  the  ulnar  in  the  ulnar  groove  by  blunt  violence,  or  if  the 
radial  is  affected  in  a  fracture  of  the  head  of  the  radius,  the  determination 
of  the  nature  and  extent  of  the  injury  is  often  impossible,  and  the  prog- 
nosis can  only  be  given  with  probability.  In  many  instances  of  subcu- 
taneous injury  it  is  difficult  to  determine  between  division  of  the  nerve 
and  severe  contusion,  as  the  latter  can  completely  inhibit  the  function 
of  the  nerve.  If  the  nerve  is  severed,  reaction  of  degeneration  appears 
in  the  muscles  supplied  by  the  nerve  in  fourteen  days;  exposure  and 
suture  of  the  nerve  are  then  indicated.  If,  on  the  other  hand,  no  degen- 
eration-reaction is  evident  and  the  paralysis  continues  unchanged  for 
weeks,  the  question  of  operation  is  difficult.  If  the  paralysis  increases, 
the  surgeon  should  convince  himself  of  the  nature  and  extent  of  the 
injury  by  examination.  There  are  cases,  however,  giving  a  doubtful 
prognosis  at  the  outset,  in  which  the  paralysis  gradually  decreases  and 
disappears  in  the  course  of  months  without  operation. 

With  the  modern  technic  it  is  better  not  to  wait  too  long,  but  to 
operate.  The  importance  of  asepsis  is  self-evident;  the  ends  of  the 
nerves  are  sought,  and  if  irregular  are  trimmed  up,  and  approximated. 
In  the  Leipzig  clinic  sutures  of  fine  silk  are  always  used.  The  suture 
is  introduced  into  the  sheath  of  the  nerve  a  short  distance  from  the  end, 
passed  along  underneath  the  sheath,  and  out  again  about  \  inch  above, 
turned  back,  and  passed  in  the  same  manner  but  in  the  opposite  direc- 
tion through  the  sheath  of  the  other  stump.  Several  sutures  are  intro- 
duced thus  around  the  nerve,  and  a  retention  suture  passed  through 
the  stumps  farther  from  the  ends.  In  applying  the  dressing,  the  hand 
should  be  fixed  so  as  to  relax  and  prevent  any  tension  upon  the  sutures. 
The  hand  should  be  immobilized  for  three  weeks,  and  then  motion 
begun  slowly. 

The  results  of  suture  vary.  Full  recovery  of  motion  and  sensation  is 
unquestionably  possible  in  cases  of  complete  division  of  the  nerve.  The 
time  varies  in  which  motion  returns  after  suture,  depending  upon  how 
soon  the  latter  follows  the  injury.  Some  statistics  give  the  time  as  a 
few  days  or  weeks;  the  usual  period,  however,  is  decidedly  longer,  the 
first  motion  commonly  appearing  at  the  end  of  six  months,  completely 
in  nine  to  ten  months.  During  this  period  atrophy  of  the  muscles  should 
be  prevented  by  electricity,  massage,  baths,  etc.  With  the  return  of 
conduction  movement  is  first  possible  indirectly  through  the  will-impulse; 
later  the  nerves  react  to  electricity. 

If  a  portion  of  the  nerve  is  lacking  in  the  forearm  or  at  the  elbow, 
it  is  harder  to  know  what  procedure  to  advise.  The  proposal  to  approxi- 
mate and  unite  the  separated  ends  of  the  nerves  by  excising  a  piece  of 


240     MALFORMA  TIONS  AND  DISEASES  OF  ELB 0  W  AND  FOREARM. 


Fig.   155. 


J 


bone,  as  employed  by  Lobker  and  v.  Bergmann  in  the  forearm,  in  the 
upper  arm  by  Trendelenburg,  is  applicable  only  in  exceptional  cases. 
If  the  nerves  cannot  be  stretched,  they  should  be  united 
by  making  lateral  flaps  turned  back  from  the  ends  of 
the  stumps.  (Fig.  155.)  Experiments  have  been  made 
on  animals  to  prepare  a  path  for  the  growth  of  the 
nerve  by  various  means — decalcified  tubes  of  bone, 
nerve-sections  from  other  animals,  strands  of  catgut — 
but  any  judgment  of  these  methods  and  their  results 
is  impossible  at  the  present  time. 

The  rare  dislocation  of  the  ulnar  nerve  may  result 
from  trauma.  Schwarz  collected  10  cases.  The  cause 
is  forcible  extension  of  the  arm.  As  the  dislocation 
known  as  "snapping"  of  the  ulnar  is  liable  to  become 
chronic,  it  is  necessary  to  fasten  the  nerve  in  the  ulnar 
groove;  the  triceps  tendon  has  been  sutured  over  it,  or 
a  muscular  flap,  freed  from  one  of  the  muscles  attached 
to  the  internal  epicondyle  and  drawn  backward  and 
sutured  over  it.  The  neuritis  occasionally  accompany- 
ing this  dislocation  is  very  disagreeable. 

Tendon-transplantation  as  a  method  for  partial  res- 
toration of  the  function  of  paralyzed  muscles  has  be- 
come generally  known  only  in  the  last  ten  years.  In 
1882  Nicoladoni  first  recommended  transplanting  the  tendons  of  par- 
alyzed muscles  to  sound  muscles  to  overcome  certain  paralyses  of 
the  leg,  such  as  frequently  follow  cerebral  paralysis  in  children.  Pre- 
viously the  peripheral  end  of  a  tendon  had  been  sutured  to  an  ad- 
joining sound  tendon,  in  cases  in  which,  following  division  of  the 
tendon,  the  ends  could  not  be  reunited  with  good  results.  In  this 
manner  Krynski  helped  a  case,  in  which  he  could  not  find  the  proximal 


Plastic  operation  for 
nerve-suture. 


Fig.  156. 


Fibrosarcoma  of  the  median  nerve,     (v.  Bruns.) 


end  of  the  flexor  tendon  of  the  middle  finger,  by  implanting  the  distal 
end  into  the  adjoining  tendon  of  the  index  finger.  Drobnik  did  a  trans- 
plantation after  the  manner  of  Nicoladoni  in  the  forearm  of  a  girl  affected 
with  paralysis  of  the  extensor  communis,  extensor  carpi  ulnaris,  the 
interossei,  and  abductor  pollicis,  in  the  following  manner:  He  split  the 
extensor  carpi  radialis  longitudinally  and  sutured-  the  inner  portion  of 
the  proximal  stump  to  the  upper  surface  of  the  tendon  of  the  extensor 


CONTRACTURES  AT  THE  ELBOW. 


241 


communis.  In  two  weeks  the  patienl  could  open  her  hand  and  gradually 
learned  to  grasp  lighl  objects.  Such  transplantation  in  the  forearm  will 
never  be  so  applicable  to  the  complicated  movements  of  the  hand  and 

fingers  as  it  is  to  the  leg;  nevertheless,  there  are  eases,  as  shown  by  more 
recent  observations  and  results,  in  which  this  treatment  is  beneficial  in 
appropriate  instances  of  paralysis  of  individual  groups  of  muscles,  and 
particularly  of  paralysis  of  those  supplied  by  the  radial. 

Fibroma,  occasionally  multiple,  and  sarcoma  occur  in  the  nerves  of 
the  arm.  (Fig.  156.)  Neuralgia  in  the  arm  is  rare.  Paralyses  or 
spasms  in  the  muscles  of  the  forearm  or  the  hand  of  central  origin  do 
not  belong  in  this  section;  in  some  instances  slight  improvement  has  been 
effected  by  means  of  mechanical  apparatus,  hut  the  results  are  insig- 
nificant. Improvement  from  the  regular  use  of  gymnastics,  electricity, 
massage,  and  baths  has  been  observed  frequently. 


CONTRACTURES  AT   THE  ELBOW. 


Fig 


Dermatogenous  contractures  and  their  treatment  were  discussed  under 
Wounds  and  Defects  of  the  Skin.  Contractures  of  nervous  origin  from 
paralysis,  aside  from  the  forms  related  in  the  preceding  section,  are  not 
amenable  to  surgical  treatment.  Myogenic  and  tendinogenic  contractures 
are  more  amenable  to  orthopedic 
treatment  combined  with  massage 
and  exercises  than  to  operative  in- 
terference (tenotomy).  In  all  injuries 
the  prevention  or  prophylaxis  of  con- 
tractures is  most  important.  If  al- 
ready developed,  they  may  be  over- 
come sometimes  by  excising  the 
cicatrix,  or  the  tendons  may  be 
lengthened  by  tenotomy  and  suture 
of  the  stumps  in  the  same  manner  as 
indicated  in  Fig.  155  for  the  suture 
of  the  nerve.  Tenotomy  may  be 
necessary  for  flexion  contractures  of 
the  fingers  if  the  nails  cut  into  the 
palm  and  produce  pain  and  ulcera- 
tion. 

Myogenic  contractures  can  result 
from  inflammation  and  phlegmon 
in  the  forearm;  from  contusion;  from  fractures.  In  the  latter  case  the 
cause  may  be  not  the  fracture  itself,  but  the  constriction  of  a  tight 
splint,  the  resulting  stasis  and  insufficient  nourishment  leading  to  the 
destruction  of  the  muscle  and  subsequently  the  so-called  ischemic 
contracture.     The  danger  of  such  improper  treatment  was  emphasized 


Ossification  of  the  biceps  tendon  following 
injury  of  the  elbow. 


1  See  section  on  Contractures  and  Ankylosis  of  the  Hand. 
Vol.  Ill— 16 


242     MALFOBMA  TIONS  AND  DISEASES  OF  ELB 0  W  AND  FOREARM. 

under  Fractures,  and  the  frequent  occurrence  of  gangrene  of  the  arm 
from  improper  splints  was  mentioned.  An  affection  at  the  elbow  usually 
mistaken  for  myogenic  contracture  is  the  not  infrequent  ossification  of 
the  biceps  tendon,  as  indicated  in  Fig.  157.  Sudeck  has  seen  such  cases 
following  injury.  The  disturbance  of  motion  is  usually  rather  marked. 
The  growth  is  attached  to  the  bone  by  a  pedicle.  Berndt  regards  the 
periosteum  as  the  origin  of  this  ossification  of  the  muscle,  as  he  found 
a  connection  between  the  two  in  every  case.  On  palpation  a  firm 
resistance  is  felt  in  the  elbow  which  is  usually  diagnosticated  as  callus. 
Whether  or  not  extirpation  would  produce  improvement  has  not  been 
sufficiently  demonstrated  by  experience. 


CHAPTEE  XIII 


MALFORMATIONS  OF  THE  BONES  OF  THE  FOREARM. 

Complete  absence  of  the  forearm  has  already  been  discussed.  Of 
the  congenital  defects  of  the  bones  of  the  forearm,  the  author  will  describe 
briefly  total  and  partial  defect  of  the  radius.  In  1895  W.  Kiimmel  collected 

Fig.  158. 


Congenital  hy] 


68  cases  of  this  sort;  in  nearly  half  of  the  cases  the  defect  involved  both 
the  radius  and  ulna.  Certain  concurrent  and  almost  typical  manifesta- 
tions of  inhibited  development  in  the  arm  concerned  point  to  the  existence 
of  such  a  defect;  the  thumb  and  its  metacarpus  are  often  lacking.     In 

(243) 


244      MALFORMATIONS  OF  THE  BOXES  OF  THE  FOREARM. 

the  wrist  the  carpal  bones  are  wanting  on  the  radial  side.  In  the  forearm 
the  radial  group  of  muscles,  the  supinators,  and  the  muscles  for  the 
thumb  are  absent.  Combined  with  this  there  may  be  an  abnormal 
condition  of  the  biceps  in  the  absence  of  the  long  head;  the  bicipital 
groove  on  the  humerus  may  also  be  wanting;  motion  at  the  elbow-joint 
is  frequently  limited. 

Partial  defect  of  the  radius,  usually  of  the  lower  end,  is  accompanied 
by  corresponding  anomalies  in  development,  as  in  the  case  of  total 


Fig 


X-ray  of  Fi 


defect.  Fig.  158  shows  a  hypoplasia  of  the  radius  with  the  characteristic 
position  of  the  hand,  seen  also  in  cases  of  total  defect.  The  thumb  is 
evidently  backward  in  development.  The  x-ray  picture  Fig.  159  shows 
the  retarded  development  of  the  radius  and  of  the  thumb,  compared  to 
that  of  the  ulna  and  the  other  fingers. 


MALFORMATIONS  OF  THE  BONES  OF  THE  FOREARM.       245 

Congenital  defecl  of  the  ulna,  much  less  frequent  than  that  of  the 
radius,  is  usually  partial,  and  may  affect  the  upper  or  the  lower  end; 
it  is  often  accompanied  by  defects  of  the  fingers  and  of  the  metacarpal 
and  carpal  hones  on  the  ulnar  side.  The  diagnosis,  easily  established 
hv  palpation,  is  made  in  detail  with  the  .r -niv,  as  shown  in  the  picture 
of  a  defect  of  the  ulna.      (Fig.  160.) 

Fig.  100. 


Congenital  defect  of  the  ulna. 


Etiology  and  Pathogenesis. — The  action  of  adherent  amniotic  bands 
cannot  be  disregarded  in  many  instances,  particularly  as  small  cicatricial 
depressions  are  sometimes  recognizable  at  the  lower  end  of  the  forearm 
as  evidence  of  such  alteration.  The  heredity  in  other  cases  points  more 
to  embryonal  maldevelopment. 

Treatment. — Treatment  is  directed  chiefly  against  the  abnormal  posi- 
tion of  the  hand  produced  by  the  deformity.  The  hand  is  sometimes 
deflected  toward  the  affected  side  and  flexed  strongly  if  the  muscles  are 
defective.     For  such  contractures  correction  is  attempted  by  manipula- 


246  MALFORMATIONS  OF  THE  BONES  OF  THE  FOREARM. 

tion  or  by  means  of  a  splint.  Marked  muscular  contraction  will  often 
require  tenotomy,  especially  of  the  flexors  or  extensors  of  the  wrist, 
according  to  the  position  of  the  hand.  The  tendons  of  the  fingers  should 
be  preserved  if  possible.  The  opposite  treatment  is  required  for  those 
forms  of  congenital  defect  of  the  radius  in  which  the  wrist-joint  is 
compromised  in  its  function  by  a  relaxed  condition.  In  such  instances, 
if  it  is  not  desirable  to  use  sheath  apparatus,  the  wrist  may  be  fixed  with 
pegs  passed,  according  to  Bardenheuer,  through  the  lower  surface  of 
the  ulna  and  the  carpal  bones  after  incising  the  joint. 

Similar  deformities  of  the  hand  may  be  acquired  in  rare  cases  from 
unequal  growth  of  the  bones  of  the  forearm.  If,  for  example,  the  growth 
of  the  radius  is  retarded  by  osteomyelitis,  the  ulna  pushes  the  hand  into 
a  position  of  radial  adduction.  In  a  case  of  this  sort  Oilier  corrected 
the  deformity  by  chondrectomy,  that  is,  by  resecting  the  lower  epiphysis 
of  the  ulna. 


PLATE  V. 


FIG.  i. 


Fracture  of  Radius;  marked  Angular  Displacement.     (Stimson. 

FIG.  2. 


Fracture  of  Radius  and  Ulna  in  Middle  Third,  showing 
So-called  "Hammock  Curve."     iSolley.) 


CHAPTER  XIV. 

INJURIES  OF  THE  BONES  OF  THE  FOREARM. 
FRACTURE  OF  THE  SHAFT  OF  THE  BONES  OF  THE  FOREARM. 

The  ulna  and  radius  are  in  contact  at  the  ends,  but  between  the  shafts 
a  space  exists  in  which  is  stretched  the  interosseous  ligament.  The 
articulation  of  the  head  of  the  radius  with  the  upper  end  of  the  ulna 
allows  the  radius  to  be  rotated  in  pronation  and  supination  around  an 
axis  extending  from  the  head  of  the  radius  to  the  middle  of  the  lower 
end  of  the  ulna;  during  rotation  the  interosseous  space  is  narrowed  or 
widened,  an  important  fact  in  the  treatment  of  fractures. 

Fracture  of  both  bones  of  the  forearm  is  a  frequent  injury.  The  cause 
is  usually  direct,  a  force  striking  the  forearm  from  the  side,  as  a  blow, 
pressure,  crushing,  etc. ;  indirect  violence,  such  as  a  fall  upon  the  hand, 
is  a  less  frequent  cause  and  commonly  affects  the  lower  third.  The 
fracture  is  relatively  frequent  in  children.  The  weakest  part  of  the 
radius  is  its  middle;  of  the  ulna,  the  lower  third.  If  the  violence  is  direct, 
the  bones  usually  break  at  the  same  level;  in  92  cases  Oberst  found  the 
break  at  the  same  level  in  50,  in  31  the  fracture  of  the  radius  was  higher; 
in  11  that  of  the  ulna  higher;  the  lower  third  and  junction  of  the  lower 
and  middle  thirds  were  affected  in  52;  the  middle  third  in  36,  the  upper 
third  in  94. 

Infraction  is  said  to  occur  rather  frequently  in  the  forearm,  presumably 
with  marked  angular  inflexion.  The  conception  of  infraction  in  such 
instances  is  much  too  broad;  the  avray  shows  that  almost  all  these 
apparent  infractions  are  transverse  fractures  with  little  or  no  displace- 
ment; infraction  is  common  only  in  children  up  to  the  twelfth  year 
(green-stick  fracture). 

The  line  of  fracture  is  usually  transverse;  less  frequently  oblique,  or 
a  longitudinal  fissure  or  spiral;  there  may  be  no  displacement  of  the 
fragments.  If  extensive  damage  of  the  soft  parts  occurs  as  a  result  of 
marked  violence,  the  displacement  of  the  four  fragments  may  be  con- 
siderable. The  direction  of  the  displacement  depends  upon  the  direction 
of  the  violence,  the  weight  of  the  arm,  and  to  a  less  extent  upon  muscular 
action. 

Symptoms. — The  symptoms  vary  according  to  the  form  of  fracture. 
Where  the  displacement  is  slight,  the  diagnosis  depends  upon  the  swell- 
ing, localized  fracture-pain,  and  false  motion.  Crepitus  is  obtained  only 
by  forced  motion.  The  hand  of  the  affected  arm  is  supported  by  the 
other  hand;  when  held  thus,  one  not  infrequently  observes  the  angular 
deformity  at  the  point  of  fracture  produced  by  gravity,  even  where  the 

(247) 


248 


INJURIES  OF  THE  BONES  OF  THE  FOREARM. 


displacement  is  slight,  the  so-called  "hammock  curve."  The  inflexion 
of  the  forearm  may  form  an  angle  opening  inward  or  outward,  accord- 
ing to  the  direction  of  the  force.  In  view  of  the  numerous  variations  in 
the  position  of  the  fragments  observed  in  fractures  of  the  forearm,  it 
seems  improbable  that  muscular  action,  as  claimed  by  many,  has  any 
great  influence  upon  the  position. 

Prognosis. — The  prognosis  depends  partly  upon  the  degree  and  form  of 
displacement,  as  the  latter  may  prevent  proper  coaptation  of  the  frag- 
ments. If  in  the  common  form  of  fracture,  namely,  with  the  fracture- 
line  at  the  same  level  in  both  bones,  the  callus  is  very  thick,  even  if  the 

Fig.  161. 


Fracture  of  both  bone 


rm  with  marked  displa< 


(Trendelenburg.) 


displacement  is  slight,  pronation  and  supination  may  be  impaired.  If 
the  callus  of  the  two  bones  grows  together  (Fig.  163),  forming  a  synos- 
tosis, rotation  may  be  checked  completely.  If  the  fragments  are  greatly 
displaced,  so  that  the  ends  are  widely  separated  laterally,  as  shown  in 
the  x-ray  picture  (Fig.  161),  the  lower  fragment  of  the  radius  is  almost 
apposed  to  the  upper  fragment  of  the  ulna,  so  that  improper  union 
and  functional  loss  occur  very  easily.  In  addition  to  this  lateral  dis- 
placement the  fragments  often  overlap  each  other  and  the  forearm  is 
shortened.  (Fig.  161.)  The  displacement  may  be  such  that  the  four 
fragments  converge  and  become  approximated,  or  diverge  and  become 
widely  separated  after  the  interosseous  ligament  is  torn.     The  lower 


FRACTURE  OF  THE  SHAFT  OF  THE  BONES  OF  THE  FOREARM.    249 

fragments  may  be  supinated  or  pronated  more  than  the  upper.    All  these 
displacements  are  significant  for  the  prognosis,  as  union  in  an  abnormal 

position  may  produce  various  disturbances  of  motion. 

Multiple  fractures  may  occur  in  many  forms  (Fig.  162);  in  these 
cases  coaptation  of  the  fragments  is  extremely  difficult. 

The  callus  formation  mentioned  above  cannot  be  held  responsible 
for  the  impairment  of  motion  in  all  cases,  v.  Volkmann  pointed  out  that 
the  hand  often  remains  pronated  and  cannot  be  supinated.     If  the  callus 


Fig.  1()2. 


Fig.  163. 


Multiple  fraetun 


Fracture  of  both  bones  of  the  fore- 
arm united  by  a  bridge  of  callus, 
(v.  Brims.) 


is  supposed  to  cause  this  impairment,  it  is  not  clear  why  supination,  by 
which  the  bones  are  separated  and  not  approximated,  should  be  limited. 
Other  factors  must  be  concerned.  Konig  attributes  this  limitation  to  the 
fact  that  union  often  takes  place  with  the  hand  and  the  lower  fragment 
pronated,  while  the  upper  fragment  is  supinated,  so  that  the  fragments 
unite  rotated  upon  each  other.     The  supination  of  the  hand  is  thus 


250 


INJURIES  OF  THE  BOXES  OF  THE  FOREARM. 


Fig.  104. 


limited  to  the  small  arc  through  which  the  upper  fragment  can  still 
supinate.  The  cause  is  therefore  union  with  displacement  at  the  periph- 
ery. The  limitation  may  also  be  the  result  of  union  with  axial  displace- 
ment if  the  forearm  is  meanwhile  pronated.  If  union  takes  place  with 
the  arm  angularly  inflexed  and  pronated,  the  interosseous  ligament  is 
stretched  at  the  point  of  inflexion  by  slight  rotation,  as  it  is  too  short 
for  the  false  position  and  for  the  wide  excursion  of  the  bones  at  the  point 
of  deformity  during  rotation,  v.  Volkmann  showed  that  angular  union 
of  one  bone  of  the  forearm,  either  the  radius  or  the  ulna,  may  cause  the 
same  limitation  of  supination,  in  that  during  rotation  the  interosseous 
ligament  cannot  follow  the  excursion  required  at  the  angle. 

Treatment. — The  knowledge  of  these  displacements  and  the  disturb- 
ances produced  by  them  is  very  essential  for  the  treatment.    The  ordinary 

transverse  fracture  without  displaee- 
_  ment  heals  in  three  to  four  weeks 
by  simply  immobilizing.  Whatever 
splint  is  used  should  extend  above 
the  elbow  and  below  the  wrist  to 
prevent  rotation.  The  fingers  should 
remain  free  and  be  exercised  actively 
and  passively  to  prevent  stiffness. 
It  has  been  known  for  a  long  while 
that  the  approximation  of  the  frag- 
ments of  the  forearm  depends  upon 
the  position  of  the  hand  in  rota- 
tion. Formerly  the  attempt  was 
made  to  separate  the  bones  of  the 
forearm  by  coaptation  pads  applied 
beneath  the  splint  upon  the  front 
and  back  of  the  forearm,  but  as  they 
were  apt  to  produce  constriction  and 
circulatory  disturbances  they  were 
abandoned.  The  separation  of  the 
bones  of  the  forearm  is  secured  more 
easily  by  immobilizing  the  hand  in 
supination  or  in  semirotation,  the  so-called  "intermediary"  position. 
Marked  displacement  of  the  fragments,  as  in  Fig.  161,  may  necessitate 
anaesthesia  to  effect  apposition;  strong  traction  is  made  upon  the  hand, 
the  upper  arm  being  held  semiflexed,  together  with  direct  manipulation 
of  the  fragments.  As  mentioned,  exact  adaptation  of  the  fragments  is 
very  important  for  the  subsequent  function  of  the  arm.  For  severe 
fractures  the  a*- ray  should  be  used  if  possible  as  control.  Angular 
inflexion  should  be  corrected  and  prevented  by  supinating  the  hand. 
If  in  the  case  of  children,  by  reason  of  the  shortness  of  the  forearm, 
a  strip  splint  cannot  be  applied,  the  entire  arm  may  be  immobilized 
extended  with  the  hand  supinated.  As  direct  violence  is  the  common 
cause  of  fractures  of  the  forearm,  compound  fractures  are  not  infrequent, 
as  from  machinery  accidents,  run-over  accidents,  etc.    Perforating  frac- 


Old  fracture  of  both  hones  of  the  forearm 
with  overriding. 


FRACTURE  OF  THE  S1IAFT  OF  THE  ULNA.  251 

tures  of  the  lower  third  of  the  arm  also  result  from  a  fall  upon  the  hand. 
There  is  nothing  particular  to  add  in  regard  to  their  treatment;  the  edges 
of  the  wound  arc  excised  after  appropriate  cleansing  and  disinfection; 
if  the  projecting  fragments  are  much  soiled,  a  portion  may  be  resected. 

The  subsequent  treatment  of  fractures  of  the  forearm  should  aim 
to  prevent  stiffness  of  the  fingers  and  hand  by  timely  removal  of  the 
splint;  further,  the  ringers  should  he  exercised  during  immobilization. 
In  three  to  four  weeks  union  is  usually  sufficiently  firm  to  permit  of  re- 
moval of  the  splint.  Stiffness  of  the  fingers  and  the  wrist  should  then 
be  overcome  energetically  by  massage  and  active  and  passive  motion. 
If  malposition,  especially  inflexion  at  the  point  of  fracture,  produces 
much  limitation  of  motion,  improvement  may  be  obtained  by  osteotomy. 
Synostoses  or  callus  compromising  the  function  are  occasionally  oper- 
able in  view  of  the  protection  afforded  by  modern  asepsis. 

Pseudarthrosis  occasionally  results  from  these  fractures,  even  where 
the  displacement  is  slight.  In  some  instances  the  cause,  whether  an 
interposition  of  soft  parts  or  lack  of  bone  production,  is  not  known. 
It  has  been  observed  also  following  fracture  of  one  of  the  bones,  and 
following  compound  fractures  in  which  portions  of  the  bone  were 
removed  on  account  of  extensive  destruction  or  infection ;  in  these  latter 
cases  the  false  joint  may  be  so  loose  as  to  give  the  so-called  "flail-hand," 
the  lower  part  of  the  forearm  swinging  like  a  pendulum  at  every  move- 
ment. 

The  treatment  of  pseudarthrosis  is  often  difficult.  Of  the  various 
methods  proposed  to  stimulate  ossification,  the  author  will  mention  only 
the  insertion  of  ivory  pegs  and  suture  of  the  bone.  As  the  first  method 
is  not  always  successful,  it  is  advisable  in  the  forearm,  in  which  the 
bones,  especially  the  ulna,  are  very  accessible,  to  suture  the  fragments 
with  iron  or  bronze  wire.  Suture  of  the  ulna  is  not  difficult,  on  account 
of  its  superficial  position;  in  suturing  the  radius  the  nerves  should  be 
guarded.  If  the  fragments  can  be  drawn  apart,  they  may  be  drilled 
and  sutured.  In  other  instances  in  which  it  is  not  desirable  to  freshen 
the  fragments  a  figure-of-8  wire  spiral  may  be  wound  around  them. 

If  operation  is  unsuccessful  or  refused  by  the  patient,  the  hand  can 
be  made  more  useful  by  a  sheath  apparatus.  Even  in  the  case  of  flail- 
hand,  wdiich  is  quite  useless  without  an  apparatus,  by  means  of  a 
simple  sheath  surrounding  the  lower  part  of  the  upper  arm  and  the 
forearm  to  the  hand,  the  hand  is  able  to  grasp  and  carry  light  objects. 


FRACTURE  OF  THE  SHAFT  OF  THE  ULNA. 

Etiology. — Isolated  fracture  of  the  shaft  of  the  ulna  is  caused  ex- 
ceptionally by  indirect  violence,  a  fall  upon  the  hand,  commonly  by 
direct  violence,  a  blow,  or  pressure;  it  occurs  very  often  in  the  form 
of  so-called  "parry-fracture,"  from  a  blow  upon  the  arm  uplifted  to 
protect  the  head.  This  blow  has  to  strike  the  ulna  alone  and  in  a 
certain  position.    The  bone  is  thus  broken  inward,  the  fragments  being 


252 


INJURIES  OF  THE  BONES  OF  THE  FOREARM. 


driven  into  the  interosseous  space.  Many  authors  question  whether 
isolated  fracture  of  the  ulna  can  he  produced  by  violent  torsion,  pro- 
nation, or  supination. 

Symptoms. — In  the  absence  of  displacement  the  fracture  is  evidenced 
by  the  localized  pain  on  pressure,  easily  obtained  by  reason  of  the 
superficial  situation  of  the  bone,  and  by  the  swelling  and  ecchymosis. 
Crepitus   and   false    motion   are  elicited    by  moving  the  fragments  on 


Fig.  165. 


Fig.  160. 


■Gunshot-fracture  of  the  ulna  (Turkish-Grecian 
War).     (Kiittner.) 


Fracture  of  the  ulna  with  dislocation  of  the 

radius. 


each  other,  if  displacement  is  more  pronounced,  the  diagnosis  is  not 
difficult;  the  edges  of  the  fragments  may  be  felt  through  the  skin.  An 
example  of  isolated  gunshot-fracture  of  the  ulna  is  shown  in  Fig.  165, 
the  ball  lying  in  the  soft  parts  of  the  lower  end  of  the  forearm.  The 
ball  entered  on  the  radial  side  of  the  upper  end  of  the  forearm,  struck 
and  fractured  the  ulna  transversely,  and  passed  downward  upon  the 
interosseous  ligament,  marking  its  path  by  a  leaden  streak. 


FRACTURE  OF  THE  SHAFT  OF  THE  RADIUS.  253 

Prognosis. — The  prognosis  of  isolated  fracture  of  the  ulna  is  favorable, 
as  the  radius  acts  as  a  splint  to  hold  the  replaced  fragments  in  position. 
The  prognosis  of  shot-wounds  or  other  compound  fractures  depends 
upon  the  course  of  the  wound. 

Treatment. — A  simple  splint  is  sufficient;  union  usually  occurs  in 
three  to  four  weeks.  Operative  reduction  is  seldom  necessary,  as  the 
functional  results  are  good  in  spite  of  persisting  displacement. 


FRACTURE  OF  THE  ULNA  WITH  DISLOCATION  OF  THE  RADIUS. 

In  the  section  on  Dislocation  of  the  Radius  it  was  mentioned  that 
fracture  of  the  ulna  is  not  infrequently  accompanied  by  dislocation 
of  the  radius.  The  combination  results  either  from  direct  violence 
applied  on  the  outer  side  of  the  arm  and  breaking  first  the  ulna,  then 
causing  the  dislocation  of  the  radius;  or  it  may  result  indirectly  from 
a  fall  upon  the  hand  or  from  a  combination  of  several  forces.  Under 
Injuries  of  the  Elbow-joint  the  author  discussed  the  symptoms,  prog- 
nosis, and  treatment  of  this  injury,  and  noted  that  the  ulna  is  almost 
always  fractured  in  the  upper  third.  The  accompanying  illustration 
(Fig.  166)  shows  the  manner  of  displacement  of  the  fragments.  Helferich 
and  Dorfler  think  that  the  fracture  is  situated  in  the  upper  third  without 
exception.  Oberst's  experience  does  not  verify  this  opinion,  and  the 
author  has  seen  2  cases  in  which  the  fracture  was  in  the  middle  third. 
For  details  of  the  diagnosis  and  discussion  of  the  difficulty  of  maintain- 
ing the  reposition  of  the  head  of  the  radius  the  reader  is  referred  to 
the  section  on  Dislocation  of  the  Radius. 

Diagnosis. — Fracture  of  the  ulna  is  usually  recognizable  by  the  angular 
inflexion  at  the  point  of  fracture  and  the  depression  of  the  skin.  There 
is  generally  evident  shortening  of  the  forearm  from  displacement  of 
the  fragments.  False  motion  and  crepitus,  more  distinct  during  rotation, 
confirm  the  diagnosis. 

Treatment. — The  fragments  are  reduced  by  direct  pressure  and  the 
dislocation  of  the  radius  overcome  by  traction  upon  the  forearm  and 
pressure  upon  the  head.  The  arm  is  immobilized  in  semiflexion  or 
acute  flexion  with  the  hand  in  semirotation.  At  the  end  of  the  third 
or  fourth  week  the  splint  is  removed  and  massage  and  exercise  begun. 
If  the  head  of  the  radius  shows  a  tendency  to  dislocate,  it  may  be  held 
in  place  by  traction  and  pressure  upon  the  head  of  the  radius  and  the 
upper  end  of  the  shaft.  This  is  most  effective  if  the  head  is  dislocated 
forward.  The  necessity  of  occasionally  resecting  the  head  has  been 
discussed  elsewhere. 

FRACTURE  OF  THE  SHAFT  OF  THE  RADIUS 

Fractures  of  the  head  and  neck  of  the  radius  were  discussed  under 
Fractures  of  the  Elbow.  The  frequent  fracture  of  the  lower  epiphysis 
of  the  radius  will  be  discussed  in  the  section  on  the  Wrist-joint. 


254  INJURIES  OF  THE  BONES  OF  THE  FOREARM. 

Etiology. — Fracture  of  the  shaft  of  the  radius  is  caused  by  direct 
violence,  as  a  blow,  pressure,  crushing;  less  frequently  indirectly,  by 
a  fall  upon  the  hand.  The  line  of  fracture  is  commonly  transverse; 
it  may  be  longitudinal  or  spiral  when  produced  by  forced  pronation 
or  supination.  The  displacement  of  the  fragments  is  usually  slight; 
it  has  a  distinct  form  according  as  the  fracture  lies  above  or  below  the 
insertion  of  the  pronator  teres,  as  the  effect  of  pronation  and  supination 
acts  in  various  ways;  in  general  the  influence  of  the  muscles  upon  the 
position  of  the  fragments  is  not  to  be  overestimated.  The  upper  frag- 
ment of  the  radius  is  inclined  to  become  supinated  and  be  displaced 
backward;  the  lower  fragment  to  become  pronated  and  enter  the  inter- 
osseous space.  The  middle  third  is  the  common  seat  of  fracture.  Oberst 
notes  the  frequent  coexistence  of  fracture  of  the  styloid  process  of  the 
ulna,  which  is  also  often  reported  with  isolated  fracture  of  the  shaft  of 
the  ulna. 

Diagnosis. — The  diagnosis  is  made  from  the  swelling,  localized 
tenderness  on  pressure,  and  crepitus  with  false  motion;  pronation  and 
supination  and  the  use  of  the  hand  are  lost.  If  the  displacement  is 
slight  in  muscular  subjects,  accurate  diagnosis  may  be  difficult. 

Treatment. — The  treatment  is  usually  simple,  good  apposition  and 
immobilization  in  a  strip  or  plaster  splint  being  sufficient.  Union  takes 
place  in  three  to  four  weeks.  The  hand  should  also  be  immobilized  supi- 
nated in  the  splint  with  the  fingers  free.  If  the  fragments  are  markedly 
displaced,  proper  apposition  is  impossible  in  many  cases  even  by  traction 
on  the  hand  and  direct  manipulation  of  the  fragments;  if  care  is  taken, 
however,  to  fix  the  hand  in  supination,  the  limitation  of  rotation  is 
usually  slight.  The  measures  advised  for  isolated  fractures  of  the  ulna 
and  fractures  of  both  bones  of  the  forearm  apply  to  angular  union  of 
the  ulna. 


CHAPTER   XV. 

•     DISEASES  OF  THE  BONES  OF  THE  FOREARM. 
OSTEOMYELITIS  OF  THE  BONES  OF  THE  FOREARM. 

Osteomyelitis  of  the  radius  or  ulna  is  rare.  In  470  cases  reported 
by  Haaga  from  v.  Brims'  clinic  the  radius  was  affected  in  5  per  cent., 
the  ulna  in  3  per  cent,  of  the  cases. 

Symptoms. — In  regard  to  the  general  symptoms,  there  is  nothing 
characteristic  to  add  to  the  well-known  general  features  of  osteomyelitis. 
The  local  inflammation  and  tenderness  are  limited  to  the  diseased  bone, 


Fig.  167. 


Fig.  168. 


Sequestrum  in  the  ulna  from  osteomyelitis. 
(v.  Bruns.) 


Osteomyelitis  of  the  radius  and  ulna. 


the  radius  or  ulna.  After  perforating  through  the  periosteum  the  suppu- 
ration spreads  rapidly  in  the  numerous  intermuscular  spaces  and  soon 
leads  to  extensive  swelling  of  the  entire  arm.  If  the  process  begins  in 
the  epiphyseal  lines  of  the  upper  ends  of  the  bones  of  the  forearm,  it  is 
accompanied  by  purulent  inflammation  of  the  joint.  The  wrist-joint 
may  also  be  attacked  by  the  inflammation.    Early  and  numerous  incisions 

(255) 


256 


DISEASES  OE  THE  BONES  UE  THE  FOREARM. 


on  the  forearm,  and  finally  drainage  of  the  joint,  will  be  required  to 
insure  free  discharge  of  pus.  The  casting  oft'  of  the  sequestrum  may 
he  expected  in  from  eight  to  ten  weeks;  its  size  may  vary  greatly. 
Occasionally,  as  shown  in  the  .r-ray  picture  Fig.  167,  small  sequestra 
lie  in  several  cavities  communicating  through  narrow  openings.  The 
entire  diaphysis,  and  more  frequently  that  of  the  radius  than  of  the 
ulna,  may  sequestrate.  The  .r-ray  demonstrates  beautifully  the  situa- 
tion of  the  cavities  and  sequestra. 

Treatment. — The  incision  for  sequestrotomy  of  the  radius  should  not 
be  too  long,  in  order  to  save  the  soft  parts.  The  bone  is  best  approached 
between  the  tendons  of  the  supinator  longus  and  extensor  carpi  radialis, 
a  little  below  the  middle  of  the  forearm.     The  incision  naturally  varies 

Fig.   169. 


Periosteal  spindle-cell  sarcoma  of  the  ulna.     ( Trendelenburg.  1 

according  to  the  position  of  the  fistula.  The  tendons  of  the  abductor 
pollicis  longus  and  extensor  pollicis  brevis  crossing  the  outer  side  of 
the  radius  at  its  lower  end  must  be  avoided. 

Sequestrotomy  is  very  simple  on  the  ulna,  as  the  bone  lies  throughout 
its  length  beneath  the  skin  on  the  inner  side  of  the  forearm,  so  that  no 
important  structures  can  be  injured  by  the  incision.  In  the  operation 
it  is  best  to  first  divide  the  fistula  and  then  gouge  out  a  gutter-shaped 
opening  along  one  edge  of  the  bone,  through  which  the  sequestrum  is 
removed.  Months  may  be  required  for  complete  closure  of  the  bony 
cavity.  Limited  mobility  of  the  fingers  and  hand,  or  even  severe  con- 
tractures, may  result  from  the  extensive  subfascial  inflammation  accom- 
panying osteomyelitis;  likewise  impairment  of  motion  or  ankylosis  of 
the  joint  from  suppuration  in  the  elbow.    Still,  fairly  good  mobility  may 


TUMORS  OF  BONES  AND  SOFT  FARTS  OF  FORFARM. 


257 


generally  be  obtained  by  timely  motion  begun  after  subsidence  of  the 
chief  symptoms  of  inflammation.  The  angers  should  never  be  included 
in  the  bandage,  and  especially  not  in  extension.  If  contractures  result 
from  improper  treatment,  good  results  may  be  obtained  by  energetic 
mechanical  treatment,  warm   baths,  and  massage. 

TUMORS  OF  THE  BONES  AND  SOFT  PARTS  OF  THE  FOREARM. 

Sarcoma  is  the  most  frequent  tumor  of  the  bones  of  the  forearm, 
and  is  either  periosteal  (Fig.   L69)  or  myeloid  (Fig.  170).     The  peri- 

Fig.  170. 


Myeloid  sarcoma  of  the  radius.     (Trendelenburg.) 

Fig.  171. 


X-ray  of  Fig.  170. 


osteal  form  is  usually  a  spindle-cell  sarcoma,  the  myeloid  a  giant-cell 
sarcoma.     Fig.   1(39  represents  a  periosteal  sarcoma  of  the  ulna  in  a 
Vol.  Ill— 17 


258  DISEASES  OF  THE  BONES  OF  THE  FOREARM. 

woman  sixty  years  old;  Fig.  170,  a  giant-cell  sarcoma  of  the  radius  in 
a  woman  thirty-two  years  old,  which  had  reached  this  enormous  size 
in  one  and  one-half  years.  The  .r-ray  picture  (Fig.  171)  of  this  tumor 
shows  its  very  extensive  growth  in  the  radius  while  the  ulna  remained 
intact.    Two  years  after  the  operation  the  patient  has  had  no  recurrence. 

Although  an  advanced  sarcoma  demands  amputation  or  exarticulation, 
smaller  tumors  of  the  bone,  especially  giant-cell  sarcomata,  which  are 
comparatively  benign,  may  permit  of  resection  of  the  bone  with  eventual 
shortening  of  the  other  sound  bone. 

Chondroma  and  chondrosarcoma  are  seen  less  frequently  in  the 
forearm  than  in  the  shoulder;  osteoma  is  also  rare.  In  cases  of  multiple 
exostosis  many  exostoses  have  been  seen  in  the  ulna  and  in  the  radius, 
chiefly  on  the  lower  end  near  the  epiphyseal  line.  The  fascial  sarcomata 
are  usually  spindle  cell,  rarely  round  cell. 

Myoma  and  mixed  tumors  are  rarities  and  only  require  mention. 
Gangrene  of  the  lower  part  of  the  forearm  is  discussed  with  the  wrist- 
joint.  Angiomata  occur  both  in  the  skin  and  the  underlying  soft  parts. 
(See  also  Diseases  of  the  Vessels  of  the  Soft  Parts  of  the  Forearm.) 


CHAPTER   XVI. 

OPERATIONS  ON  THE  ELBOW  AND  FOREARM. 

LIGATION  OF  THE  RADIAL  AND  ULNAR  ARTERIES. 

Ligation  of  the  Radial  Artery. — The  radial  artery  is  not  often  ligated 
in  the  upper  part  of  the  forearm;  incision  at  this  point  is  made  at  the 
junction  of  the  middle  and  upper  thirds  of  the  arm  at  the  inner  edge 
of  the  supinator  longus  and  pronator  teres,  and  is  continued  down 
between  the  flexor  carpi  radialis  and  supinator  longus  to  the  artery 
beneath.  On  the  radial  side  of  the  artery  lies  the  superficial  or  sensory 
branch  of  the  radial  nerve. 

It  is  more  often  necessary  to  ligate  the  artery  above  the  wrist,  where 
the  pulse  is  felt,  and  where  the  vessel  is  frequently  cut  by  trauma  or 
suicidal  attempts.  The  artery  is  found  between  the  tendons  of  the 
supinator  longus  and  flexor  carpi  radialis;  it  lies  superficially  imme- 
diately beneath  the  skin  and  thin  fascia  between  two  small  veins. 

Ligation  of  the  Ulnar  Artery. — ligation  of  the  ulnar  above  the 
middle  of  the  forearm  is  also  seldom  necessary;  if  so,  it  is  much  easier 
to  ligate  the  cubital  artery;  the  incision  is  made  on  the  inner  side  of 
the  arm  close  to  the  radial  border  of  the  flexor  carpi  ulnaris,  and  is 
continued  into  the  space  between  the  flexor  carpi  ulnaris  and  flexor 
sublimis;  these  muscles  are  pushed  aside  and  the  artery  is  seen  at  the 
bottom  of  the  wound  lying  upon  the  flexor  profundus.  The  ulnar  nerve 
lies  to  the  ulnar  side  of  the  artery. 

For  ligation  of  the  ulnar  artery  above  the  wrist,  the  incision  is  made 
to  the  outer  or  radial  side  of  the  flexor  carpi  ulnaris,  whose  tendon  is 
easily  felt  by  flexing  the  hand;  the  incision  therefore  lies  in  the  pro- 
longation of  the  outer  border  of  the  pisiform  bone.  After  dividing  the 
skin  and  thick  fascia  of  the  forearm  the  edge  of  the  tendon  of  the  flexor 
carpi  ulnaris  is  exposed.  One  must  be  careful  not  to  make  a  miscut 
beneath  this  tendon.  The  artery  with  two  small  veins  lies  beneath  the 
deep  fascia  of  the  forearm.    The  ulnar  nerve  lies  to  the  ulnar  side. 

AMPUTATION  OF  THE  FOREARM. 

Severe  injuries  of  the  hand  or  lower  part  of  the  forearm  are  not 
infrequent  indications  for  amputation.  If  the  lesion  extends  up  almost 
to  the  elbow,  one  must  choose  in  some  instances  between  amputation 
of  the  forearm  below  or  at  the  elbow.     As  already  mentioned,  a  short 

(259) 


260 


OPERATIONS  OX  THE  ELBOW  AXD  FOREARM. 


stump  of  forearm  is  very  important  for  the  use  of  the  arm  and  the 
application  of  a  prothesis,  so  that  one  should  always  choose  in  favor 
of  amputation  below  the  elbow  in  such  cases  if  possible. 

The  skin  may  be  divided  by  a  circular  incision,  and  after  a  longitudinal 
incision  on  the  radial  and  ulnar  sides  two  skin-flaps  of  equal  lengths — 
cuffs — may  be  dissected  back.  The  muscles  are  divided  by  a  circular 
incision.  The  catling  is  then  inserted  in  the  interosseous  space  on  the 
extensor  side  of  the  ulna  and  brought  out  on  the  extensor  side  of  the 
radius;  in  the  same  manner  the  soft  parts  of  the  interosseus  space  are 
divided  on  the  flexor  side.  The  two  bones  are  sawed  through  together. 
The  ulnar,  radial,  and  muscular  branches,  and  in  the  upper  and  middle 
third  the  interosseous  artery,  are  to  be  ligated  before  removing  the 
tourniquet.  The  radial  artery  in  the  upper  third  lies  at  some  depth 
between  the  supinator  longus  and  flexor  carpi  radialis  upon  the  pronator 


Radial  artery. 


Pronator  teres. 
Radial  nerve. 


Fig.  172. 

Flexor  carpi  Median  Palmaris 

radialis.      nerve,     longus.     Flexor  sublimis. 

Ulnar  artery. 


Ulnar  nerve. 


longus. 
Extensor  carpi 
radialis. 

Supinator 

b  re  vis. 


Extensor 
digituntm. 


.  np,nato>  ~k-^tj:l^m<^A^^^^m^\ 


Flexor  pro- 
fundus. 


Posterior  inter-  Extensor  Extensor  Extensor  carpi 
osseous  nerve,  minimi    pollicis      ulnaris. 
digiti.       longus. 

Cn  (SS-s eetion  of  forearm  at  junction  of  upper  and  middle  third,     i?,  radius;    V,  ulna. 


teres.  The  superficial  branch  of  the  radial  nerve  lies  to  the  radial  side 
of  the  artery.  The  ulnar  artery  in  the  upper  third  lies  between  the 
flexor  sublimis  and  profundus.  One-quarter  to  one-half  inch  to  the 
ulnar  side  in  the  same  interspace  lies  the  ulnar  nerve;  the  median  nerve 
lies  at  the  same  distance  on  the  radial  side.  The  relations  in  the  ampu- 
tation surface  are  shown  in  Fig.  172.  If  the  amputation  is  higher  up, 
the  ulnar  artery  lies  nearer  the  median  nerve;  farther  down  it  approaches 
the  ulnar  nerve.  In  the  middle  and  lower  thirds  of  the  forearm  the 
arteries  and  nerves  are  easily  located  (see  ligation  of  arteries);  here 
the  ulnar  nerve  lies  to  the  ulnar  side  of  the  artery  as  far  as  the  wrist;  the 
radial  nerve  to  the  radial  side  of  the  artery,  diverging  from  it  a  little 
below  the  junction  of  the  middle  and  lower  thirds  of  the  arm  to  proceed 
backward  beneath  the  tendon  of  the  supinator  longus. 


OPERA  TIONS  <>X  THE  NERVES  OF  THE  FOREARM.  261 

In  the  upper  third  the  median  nerve  lies  to  the  radial  side  of  the 
ulnar  artery,  beneath  the  pronator  teres  and  flexor  sublimis.  In  the 
middle  of  the  forearm  it  lies  between  the  superficial  and  deep  flexors, 
becomes  more  superficial  toward  the  hand,  and  above  the  wrist  lies 
to  the  radial  side  of  the  palmaris  longus  between  the  tendons  of  the 
flexor  sublimis. 

It  is  advisable  in  amputating  to  divide  the  nerve  one-half  to  an  inch 
higher  than  the  muscles  and  vessels,  so  that  the  ends  will  not  lie  in  the 
plane  of  the  amputated  surface  and  give  rise  to  neuromata  on  the  ends 
of  the  stumps. 

In  most  of  the  amputations  for  injuries,  the  stumps  of  the  bones  will 
be  covered  in  by  a  flap  incision  instead  of  a  circular  incision.  According 
to  the  extent  of  the  injury,  it  may  be  necessary  to  form  the  flap  on  the 
radial,  ulnar,  extensor,  or  flexor  surface.  If  the  operation  is  to  be 
bloodless,  instead  of  the  Esmarch  bandage  one  should  use  preferably 
a  broad  rubber  band,  either  of  the  style  of  Xicaise's  or  Martin's.  The 
sharp  constriction  of  the  rubber  band  causes  lesions  of  the  nerves 
resulting  in  paralysis  of  the  hand  and  forearm,  which  takes  months  to 
recover.  If  on  account  of  complicated  operations  on  the  forearm  or 
elbow  it  is  necessary  to  constrict  the  arm  more  than  an  hour,  the  bandage 
should  be  shifted  from  one  point  to  another  so  that  the  constriction  is 
not  applied  too  long  in  one  spot. 

OPERATIONS  ON  THE  NERVES  OF  THE  FOREARM. 

Suture  of  the  nerves  may  be  required  for  injuries  produced  by 
puncture,  stab,  incised,  or  gunshot- wounds;  the  position  of  the  nerves 
is  given  in  the  preceding  section. 

The  median  nerve  in  the  upper  third  of  the  forearm  is  reached  through 
an  incision  between  the  supinator  longus  and  flexor  carpi  radialis.  The 
radial  artery  is  exposed;  at  its  ulnar  side  the  pronator  teres  is  divided 
and  the  nerve  found.  Farther  down  the  nerve  passes  under  the  flexor 
sublimis.  In  the  middle  of  the  forearm  the  incision  is  made  between 
the  flexor  carpi  radialis  and  palmaris  longus.  The  flexor  sublimis  is 
drawn  aside;  beneath  it  lies  the  nerve.  Above  the  wrist  the  nerve  lies 
to  the  radial  side  of  the  palmaris  longus  between  the  tendons  of  the 
flexor  sublimis. 

The  ulnar  nerve,  lying  to  the  ulnar  side  of  the  ulnar  artery,  is  easily 
found  through  the  incision  given  for  the  artery.  In  like  manner  the 
superficial  sensory  branch  of  the  radial  nerve,  which  accompanies  the 
radial  artery  on  the  radial  side  to  the  lower  third  of  the  arm,  thence 
passing  to  the  dorsum  beneath  the  supinator  longus.  The  deep  branch 
of  the  radial  nerve  lies  hidden  beneath  the  extensor  carpi  radialis  longus. 
The  incision  is  made  below  the  head  of  the  radius  between  the  extensor 
carpi  radialis  longus  and  extensor  communis.  The  nerve  is  exposed  on 
retracting  the  muscles.  It  emerges  from  the  supinator  brevis,  which  is 
recognized  by  its  oblique  fibres.  Farther  down  it  divides  into  its  mus- 
cular branches  and  the  posterior  interosseus. 


262  OPERATIONS  ON  THE  ELBOW  AND  FOREARM. 

In  operations  on  the  forearm  for  ligation,  suture  of  nerve  or  tendons, 
operations  on  the  bones,  etc.,  the  distribution  of  the  arteries  and  nerves 
must  be  considered.  The  ulna  is  approached  without  difficulty  on  its 
inner  surface:  the  radius  is  best  exposed  through  an  incision  to  the  outer 
(radial)  side  of  the  radial  artery.  Through  this  incision  the  interosseous 
ligament  is  accessible  after  separating  the  muscles  from  the  radius;  in 
the  lower  half  of  the  arm  the  interosseous  ligament  is  approached  at 
the  side  of  the  median  nerve. 


CHAPTER  XVII. 

ACCIDENT  AND  JUDGMENT. 

A  large  proportion  of  the  accidents  requiring  medical  testimony 
are  those  resulting  from  the  manual  control  of  machinery  in  the  ex- 
tensive mechanical  industries  of  the  present  time. 

As  the  loss  of  the  hand,  the  apparatus  and  instrument  of  prehension 
and  touch,  is  conclusive  in  injuries  involving  the  loss  of  part  of  the  upper 
extremity,  the  level  of  amputation  is  of  slight  importance  in  estimating 
the  loss  in  earning-efficiency.  Further,  whether  the  amputation  is  at  the 
elbow  or  in  the  upper  or  lower  third  of  the  forearm  is  of  little  moment 
for  the  working  ability  of  the  individual.  The  degree  of  impairment 
in  earning-efficiency  is  estimated,  to  have  some  standard  of  calculation, 
at  100  per  cent,  in  the  case  of  exarticulation  or  amputation  of  both  fore- 
arms, and  in  the  loss  of  the  right  forearm,  between  70  and  80  per  cent. 
Defects  in  or  impairment  of  the  left  arm  are  usually  estimated  about 
10  per  cent,  below  the  same  in  the  right  arm;  so  the  loss  of  the  left  fore- 
arm=60  to  70  per  cent.  Loss  of  both  hands  or  forearms  is  really  not 
represented  adequately  by  an  earning-deficiency  (or  disability)  of  100 
per  cent.,  as  the  personal  attendance  required  by  the  patient  should  be 
taken  into  account;  recent  estimates  place  the  proper  percentage  at  125 
to  130  per  cent,  for  the  case  in  question,  assuming  a  loss  in  earning- 
efficiency  of  more  than  100  per  cent. 

In  injuries  of  the  nerves  of  the  forearm  resulting  in  paralyses  of  the 
hand  the  degree  of  impairment  of  the  hand  is  naturally  conclusive.  In 
paralysis  of  the  radial  the  hand  is  practically  useless  without  a  sheath 
apparatus.  If  the  right  is  affected,  the  loss  in  earning-efficiency  amounts 
to  60  to  70  per  cent.,  if  the  left  50  to  60  per  cent.;  paralysis  of  the  ulnar 
or  median  alone  is  reckoned  at  60  to  70  per  cent,  on  the  right  side,  on 
the  left,  50  to  60  per  cent. ;  paralysis  of  the  radial,  ulnar,  and  median 
combined,  on  the  right,  70  to  SO  per  cent.,  on  the  left,  60  to  70  per  cent. 
In  radial  paralysis  the  loss  in  earning-efficiency  can  be  compensated 
20  to  30  per  cent,  by  the  sheath  apparatus.  All  results  of  compound 
fractures  and  inflammations  of  the  forearm  are  estimated  as  equal  to 
the  loss  of  an  arm,  if  the  fingers  and  hand  are  entirely  stiffened.  The 
loss  in  earning-efficiency  in  ankylosis  of  the  elbow  at  a  right  angle  is 
placed  at  35  to  40  per  cent.;  at  an  obtuse  angle  or  extended,  50  to  60 
per  cent.  In  actively-loose  joint  of  the  elbow,  loss  on  the  right  side  50 
to  60  per  cent.,  on  the  left,  40  to  50  per  cent.;  in  passively-loose  joint, 
as  the  hand  is  entirely  useless,  in  the  right,  60  to  75  per  cent.,  in  the 
left,  60  to  70  per  cent.;  the  loss  is  decreased  20  to  35  per  cent,  by  sheath 

apparatus. 

(  263  ) 


264  ACCIDENT  AND  JUDGMENT. 

It  is  advisable  to  allow  co-operative  associations  a  slight  margin  in 
the  estimate;  in  other  words,  to  state  that  the  loss  in  earning-efficiency 
resulting  from  the  accident  under  consideration  is  regarded  as  about 
50  to  (>0  per  cent.  The  co-operative  association  selects,  according  to 
the  circumstances  of  the  case,  the  higher  or  lower  interest;  to  be  sure, 
there  are  considerations  influencing  the  economical  aspect  of  the  question 
which  the  physician  is  often  unable  to  estimate.  Some  of  the  co-operative 
associations  absolutely  reject  any  statement  of  the  earning-deficiency  in 
percentages,  and  desire  the  physician  to  state  definitely  as  to  how  severe 
the  injury  is;  whether  there  is  complete  loss  of  earning-efficiency  or 
whether  it  is  very  severe,  or  severe,  moderate,  slight,  or  very  slight. 
These  are  the  grades  which  they  use  as  a  basis  of  calculation.  The 
method  certainly  has  its  justifications. 

If  motion  is  limited  at  the  elbow,  after  fractures,  to  50  degrees,  the 
result  would  be  perhaps  an  earning-deficiency  of  20  per  cent.  The 
essential  element  in  the  disturbance  is  the  impairment  of  rotation  of 
the  hand;  if  it  is  checked  entirely,  the  earning-deficiency  is  always 
increased  from  15  to  20  per  cent,  for  the  right  hand,  10  to  15  per  cent, 
for  the  left.  If  stiffness  of  the  individual  fingers  results  from  severe 
laceration  of  the  muscles  of  the  forearm,  the  loss  in  earning-efficiency 
will  depend  upon  the  extent  to  which  the  motion  of  the  fingers  is  limited. 
Fractures  of  the  forearm  or  of  the  elbow  in  elderly  individuals  of  the  labor- 
ing class  are  almost  always  followed  by  more  or  less  stiffness,  muscular 
weakness,  and  oedema  in  the  hand — the  latter  being  apt  to  be  combined 
with  rheumatic  pains — and  limit  the  earning-ability;  these  sequela? 
even  follow  a  recovery  uneventful  from  the  outset,  and  in  the  common 
fractures  of  the  forearm  the  loss  incurred  varies  from  20  to  40  per  cent. 
In  younger  subjects  there  is  generally  no  permanent  loss,  but  damages 
are  collected  on  account  of  the  pain,  the  existence  of  which  often  cannot 
be  disproved. 

All  statements  of  the  time  of  recovery  of  fractures,  given  in  the  course 
of  transactions,  take  into  account  only  the  consolidation  of  the  bone. 
That  does  not  mean  that  the  fractured  limb  is  able  to  be  used,  for  as 
a  rule  the  arm  is  not  fitted  for  work  until  two  to  three  weeks  after  con- 
solidation in  the  case  of  fractures  unaccompanied  by  severe  lesions  of 
the  soft  parts,  and  not  until  four  or  five  weeks  later  where  the  soft  parts 
were  badly  contused  and  lacerated.  During  this  time  massage,  warm 
arm  baths,  electricity,  and  exercise  with  apparatus  are  understood  to 
have  been  employed. 

At  the  end  of  this  period,  in  which  the  patient  is  still  to  be  regarded 
as  unfit  for  work,  begins  the  period  of  renewed  activity  and  partial 
earning-efficiency,  in  which,  to  formulate  the  estimate,  an  earning- 
deficiency  of  about  50  per  cent,  still  persists  for  three  weeks  longer  in 
the  case  of  severe  fractures,  and  then  the  deficiency  decreases  to  about 
20  to  30  per  cent.  At  the  end  of  six  months  the  examination  determines 
whether  the  improvement  has  continued  or  whether  the  remaining 
impairment  will  be  permanent. 


MALFORMATIONS,  INJURIES,  AND  DISEASES 
OF  THE  WRIST  AND  HAND. 


By  Prop.  Dr.  P.  L.  KKrKDIUCH. 


Preliminary  Remarks  on  the  Anatomy  and  Technic  of  Examina- 
tion.— In  the  slight  compass  of  the  hand  there  are  twenty-seven  small 
bones,  compactly  arranged  and  adjustable  and  movable  by  the  action  of 
forty  muscles.  In  a  structure  capable  of  such  numerous  movements  it 
can  be  understood  how  even  slight  disturbances  may  entail  functional 
loss.  The  functional  power  of  the  hand  of  the  laboring-man  often  deter- 
mines his  entire  earning  ability.  An  accurate  knowledge  of  the  normal 
function  is  therefore  indispensable  for  the  recognition  of  pathological 
changes.  On  the  fingers  as  well  as  on  the  hand  are  distinguished  four 
sides  or  surfaces:  flexor  or  volar,  extensor  or  dorsal,  ulnar  and  radial. 
Surgeons  speak  of  flexion  (volar  flexion),  extension  (dorsal  flexion);  in 
deviation  of  the  hand  toward  the  radial  or  ulnar  side,  abduction  (radial 
inflexion),  adduction  (ulnar  inflexion). 

The  skin  of  the  fingers  on  the  flexor  side  is  well  supplied  with  tactile 
nerve-endings  and  lymphatics,  contains  more  fat  than  that  of  the 
dorsum,  is  especially  delicate  on  the  ulnar  and  radial  sides,  and  is 
therefore  easily  perforated  here  by  inflammatory  products  from  within. 

On  the  flexor  surface  of  each  finger  are  three  deep  folds,  on  the  thumb 
two,  corresponding  to  the  joints.  The  proximal  folds  do  not  lie  over 
the  metacarpophalangeal  joints,  but  y7^  to  yw  mcri  distally.  They  indicate 
the  line  of  incision  for  exarticulation  of  the  fingers.  The  next  row 
corresponds  to  the  first  interphalangeal  joints.  The  third  folds  lie 
j  inch  proximal  to  the  second  interphalangeal  joint. 

The  skin  on  the  flexor  surface  of  the  fingers  is  normally  only  slightly 
movable.  Therefore  inflammation  rapidly  causes  a  feeling  of  marked 
tension.  Strong  bands  of  connective  tissue  unite  the  skin  and  under- 
lying tendon-sheaths  at  the  folds  of  the  fingers,  so  that  in  inflammations 
of  the  skin  the  fold  is  often  deepened;  in  exudations  within  the  tendon- 
sheaths  the  folds  are  levelled  off  and  effaced.  The  folds  at  the  base  of 
the  fingers  are  held  by  peripheral  radiations  of  the  palmar  aponeurosis, 
the  distal  fibres  of  which  extend  to  the  base  of  the  second  phalanx, 
sometimes  even  to  the  terminal  phalanx. 

The  tendon-sheaths  run  immediately  beneath  the  subcutaneous  layer 
of  fat,  beginning  usually  at  the  head  of  the  metacarpus  and  ending  at  the 
base  of  the  third  phalanx.  Slight  variations  occur.  Those  of  the  thumb 
and  fifth  finger  are  somewhat  longer,  extending  almost  to  the  wrist, 

(  265  ) 


266     MALFORMATIONS  AND  DISEASES  OF  WRIST  AND  HAND. 

where  they  communicate — or  only  that  of  the  thumb — with  the  common 
tendon-sheath.  The  tendon-sheaths  are  attached  to  the  anterior  surface 
of  the  capsule  at  all  the  finger-joints,  and  on  the  phalanges  to  the  under- 
lying bone.  They  each  enclose  a  flexor  sublimits  and  profundus  tendon; 
but  on  the  thumb  only  the  tendon  of  the  flexor  pollicis  longus.  They 
are  everywhere  strengthened  by  fine  transverse  fibrous  bands  which  are 
extremely  delicate  at  the  joint  to  allow  free  motion.  The  nerves  and 
vessels  run  at  the  sides  of  the  tendon-sheaths. 

The  excess  of  skin  on  the  flexor  surface  and  the  greater  mobility  of 
the  same  on  the  extensor  surface  of  the  fingers  are  explained  by  the 
predominance  of  the  flexor  action.  Over  the  joints  on  the  dorsum  the 
average  thickness  is  only  2  mm.  so  that  slight  puncture-wounds  pene- 
trate easily;  hence  the  greater  frequency  of  inflammatory  affections  of 
the  joint  following  injuries  on  the  dorsum. 

The  vulnerability  of  the  nail-fold  favors  the  production  of  cutaneous 
inflammations  (paronychia) ;  the  abundance  of  sweat-glands  in  the  skin 
on  the  dorsum  the  production  of  folliculitis.  The  matrix  extends  back 
about  2  mm.  beneath  the  skin  fold,  as  is  easily  felt  by  pressing  upon 
the  projecting  edge  of  the  nail.  This  is  to  be  taken  into  account  in 
incising  to  extract  the  nail. 

The  extensor  tendons  lie  immediately  beneath  the  thin  skin  without 
any  particular  sheath;  their  flatness  is  increased  over  the  joints,  so  that  in 
this  situation  they  are  quite  broad.  The  end  of  the  middle  tendon  is 
inserted  in  the  base  of  the  second  phalanx,  the  two  lateral  tendons  in  the 
third  phalanx.  The  base  of  each  phalanx  can  be  felt  in  flexion  through 
the  tendons;  in  order  to  incise  upon  the  bony  margin  of  the  base  to 
exarticulate,  the  transverse  incision  is  made  2  to  7  mm.  distal  to  the  flexor 
prominence  of  the  joint.  The  dorsal  transverse  folds  over  the  joint  have 
no  value  as  landmarks.  On  account  of  the  thinness,  looseness,  and  ful- 
ness of  the  skin  on  the  dorsum  over  the  joints,  and  the  thinness  and 
width  of  the  dorsal  part  of  the  capsule,  the  skin  is  distended  like  a  sac 
by  inflammatory  exudates  in  the  joints.  All  exudates  (inflammatory, 
rheumatic,  hemorrhagic)  force  the  fingers  into  a  position  of  slight  flexion 
at  the  diseased  joint,  the  position  giving  the  greatest  room  in  the  joint, 
and  on  this  account  the  most  comfortable  position  for  prolonged  im- 
mobilization of  the  finger. 

The  metacarpophalangeal  joint  is  capable,  besides  flexion  and  ex- 
tension, of  limited  abduction  and  adduction  if  the  fingers  are  extended. 
Normally  these  lateral  movements  are  not  possible  in  the  interphalangeal 
joint;  still  it  is  characteristic  of  children,  particularly  of  the  female  sex, 
and  women,  that  frequently  the  joint-surfaces  can  be  displaced  passively 
upon  each  other  backward,  forward,  or  laterally.  The  same  applies 
to  individuals  who  have  not  recovered  from  the  effects  of  lesions  loosen- 
ing the  ligaments. 

The  excursion  of  motion  in  the  finger-joints  varies  in  the  individual. 
Normally  there  is  moderate  active  hyperextension  in  the  metacarpo- 
phalangeal joints  and  flexion  to  a  right  angle.  Passively  hyperextension 
can  be  increased  more  than  flexion.    The  interphalangeal  joints  usually 


MALFORMATIONS  AND  DISEASES  OF  WRIST  AND  HAND.     267 

permit  of  extension  only  to  a  straight  line.  Pianists  and  people  with 
unusual  suppleness  can  sometimes  increase  the  extension  considerably. 
Flexion  generally  reaches  an  acute  angle  of  about  (50  degrees.  In  the 
second  interphalangeal  joint  a  righl  angle  can  be  readied  actively  only 
with  some  effort.  In  determining  pathological  changes  the  affected 
hand  should  he  compared  with  the  sound  one  if  accessible.  This  applies 
as  well  to  measuring  the  phalanges  and  the  joints. 

Fig.  173. 


Tendon-sheaths  of  the  flexors.     Showing  relation  of  the  sheaths  to  the  deep  palmar  arch  and  the 
lines  of  the  palm.    The  latter  are  indicated  by  the  black  lines.    (His  and  Spalteholz.) 


The  position  held  by  the  thumb  is  unique.  The  free  mobility  of 
the  thumb  is  the  most  important  factor  in  the  earning-efficiency  of  the 
human  hand.  To  save  everything  that  can  be  saved  should  be  the 
surgeon's  first  principle  in  the  surgical  treatment  of  injuries  of  the 
thumb.  For  this  reason  all  functional  disturbances  affecting  the  thumb 
are  more  important  than  those  of  the  other  fingers. 


268     MALFORMATIONS  AND  DISEASES  OF  WRIST  AND  HAND. 

The  skin  of  the  palm,  often  callous  and  thickened,  is  firmly  adherent 
to  the  underlying  palmar  aponeurosis,  and  so  only  slightly  movable. 
Hair  and  sebaceous  glands  are  absent.  Hence  genuine  furuncle  and 
atheroma  do  not  occur.  It  is  only  in  diabetes  that  one  occasionally 
meets  with  a  painful  circumscribed  inflammatory  infiltration  of  the 
palm  similar  to  furuncle.  The  two  transverse  folds  in  the  palm  form  a 
line  which  marks  approximately  the  position  of  the  metacarpophalangeal 
joints  and  the  beginning  of  the  tendon-sheaths  of  the  fingers.  (See 
Fig.  173.)  The  palmar  aponeurosis  is  most  strongly  developed  in  the 
centre. 

Palpation  of  the  base  of  the  hand  on  the  dorsum  is  aided  by  many 
anatomical  points.  Running  the  first  finger  upward  along  the  radial 
side  of  the  first  metacarpal  one  feels  a  slight  projection  at  the  base  to 
which  the  tendon  of  the  abductor  pollicis  longus  is  attached.  In  the 
same  way  on  the  ulnar  side  of  the  fifth  metacarpal  one  comes  upon  a 
small  prominence  at  the  base,  and  by  ulnar  adduction  and  extension 
of  the  hand  the  extensor  carpi  ulnaris  attached  to  it  can  be  felt.  A 
slightly  curved  line,  convex  downward,  joining  these  two  bony  points 
lies  directly  over  the  line  of  the  carpometacarpal  joint.  Running  the 
finger  downward  along  the  shaft  of  the  radius  on  its  outer  side  a  slight 
bowing,  convex  toward  the  dorsum,  is  felt  at  the  lower  third,  and 
beyond,  the  club-shaped  end  of  the  bone.  Passing  inward  from  the 
styloid  process  of  the  radius  the  entire  dorsal  articular  border  of  the 
radius  can  be  felt— especially  if  the  hand  is  slightly  flexed — and  the 
line  of  the  radiocarpal  joint  (scaphoid,  semilunar,  and  cuneiform)  so 
important  for  the  movements  of  the  wrist.  This  joint  is  best  examined 
on  the  dorsum.  The  triangular  cartilage  is  the  immediate  continuation 
of  the  articular  cartilage  of  the  radius,  and  forms  the  boundary  between 
the  radio-ulnar  joint  and  the  wrist;  exceptionally  there  is  a  communi- 
cation, as  demonstrated  by  M.  Schiiler  by  injection.  The  disk  can 
be  felt  only  in  very  thin  hands.  Under  the  same  conditions  the  dorsal 
branches  of  the  radial  and  ulnar  nerves  can  be  moved  about  beneath 
the  skin. 

On  the  flexor  surface  of  the  wrist  the  tuberosity  of  the  scaphoid, 
slightly  to  the  inner  side  of  and  below  the  styloid  process,  and  the  tra- 
pezium on  the  radial  side,  and  the  process  of  the  unciform  and  pisiform 
on  the  ulnar  side,  represent  the  pillars  of  the  vaulted  arch  of  the  carpus. 
The  bones  are  frequently  contused  in  falling  upon  the  outstretched 
hand,  fragments  may  be  torn  off,  or  the  bones  may  be  crushed  and 
remain  painful  for  a  long  time. 

The  bony  structure  of  the  wrist  is  divisible  with  reference  to  motion 
into  three  parts.  Pronation  and  supination  take  place  in  the  radio- 
ulnar joint,  which  is  separated  from  the  wrist  by  the  cartilaginous  disk. 
Flexion  and  extension  take  place  between  the  cartilaginous  surfaces  of 
the  radius  and  cartilaginous  disk  and  the  condyloid  head  formed  by 
the  scaphoid,  lunar,  and  cuneiform — the  radiocarpal  joint  (first  joint). 
The  second  joint  is  composed  of  the  distal  cotyloid  surfaces  of  these 
bones  and  the  combined  condyloid  surface  of  the  os  magnum  and 


MALFORMATIONS  AND  DISEASES  OF  WRIST  AND  HAND.     269 

unciform.  The  connection  between  the  distal  carpal  row  and  the 
metacarpals  is  very  firm,  having  essentially  no  joint-action;  only  the 
first  metacarpal  forms  a  more  freely  movable  saddle  joint  with  the  os 
magnum.  \V.  Braune  and  ().  Fischer  by  careful  investigations  have 
determined  the  range  of  motion  in  the  wrist  as  a  whole  and  in  the 
several  sections.  It  appears  that  the  position  of  the  hand  has  a  decided 
influence  upon  the  range  of  motion.  Taking  the  middle  position  of 
the  hand  as  a  starting-point,  whereby  ulnar  and  radial  inflexion,  flexion 
and  extension,  are  about  equal,  it  follows  that  the  combined  movements 
of  the  hand  take  place  simultaneously  in  both  joints.  Ulnar  inflexion 
is  possible  to  20  degrees,  55  per  cent,  of  which  occurs  in  the  radio- 
carpal, 45  per  cent,  in  the  midearpal  joint.  Flexion  is  possible  to  87 
degrees,  of  which  70  per  cent,  is  in  the  first  joint,  30  per  cent,  in  the 
midearpal  (second  joint).  Radial  inflexion  (27  degrees)  and  dorsal 
flexion  (86  degrees)  take  place  chiefly  in  the  midearpal  joint.  The 
information  given  by  Braune  and  Fischer  is  verified  by  R.  Fick  in  a 
very  careful  study  with  the  ar-ray  of  the  movements  of  the  wrist.  The 
long  flexor  and  extensor  muscles  of  the  hand  control  the  position  of 
the  wrist  in  as  far  as  the  position  of  the  finger-joints  favors  or  limits 
the  range  of  motion  in  the  wrist;  inversely,  the  position  of  the  wrist 
is  significant  for  the  contraction  of  the  finger  muscles. 

The  elements  of  the  wrist  are  bound  firmly  together  in  their  proper 
position  by  strong  ligaments.  The  dense  outer  portion  of  the  anterior 
ligament  running  from  the  styloid  process  and  adjacent  articular  surface 
of  the  carpus  to  the  scaphoid,  lunar,  and  cuneiform,  holds  the  carpal 
head  formed  by  the  latter  against  the  radius.  Its  power  of  resistance 
is  greater  than  that  of  the  radius,  so  that  in  falling  upon  the  extended 
hand  the  bone  breaks  more  easily  than  the  ligament  is  torn.  The 
posterior  ligament  corresponding  to  it  is  less  firm.  The  other  flexor 
ligaments  are  also  well  developed.  The  ligament  running  from  the 
scaphoid  and  trapezium  to  the  unciform  and  pisiform  bones  also  gives 
stability;  it  covers  the  flexor  tendons  and  median  nerve.  The  inter- 
communication of  the  various  joints  is  favorable  for  the  dissemination 
of  inflammatory  processes  in  the  wrist.  As  mentioned,  the  radio-ulnar 
articulation  is  closed  off  from  the  carpus  by  the  cartilaginous  disk. 
Inflammation  rarely  spreads  from  it  to  the  carpus.  The  radiocarpal 
joint  is  separated  from  the  midearpal.  The  latter  connects  with  the 
carpometacarpal  joint  between  the  os  magnum  and  trapezoid  and 
between  the  trapezium  and  trapezoid.  The  joint  between  the  cuneiform 
and  pisiform  not  infrequently  connects  with  the  carpometacarpal  joint. 
Retention  of  secretion  is  particularly  liable  to  occur  in  the  midearpal 
joint.  From  the  above  it  can  be  understood  that  inflammation  in  the 
carpometacarpal  joint  spreads  easily  to  the  midearpal.  In  extra- 
vasation the  synovial  pockets  bulge  perceptibly  at  both  sides  of  the 
extensors  and  give  fluctuation.  The  tendon-sheaths  sometimes  com- 
municate with  the  joint  at  this  point,  and  inflammation  may  spread 
in  either  direction.  The  best  points  for  puncture  and  injection  of  the 
joints  are  below  the  styloid  process  of  the  radius  and  ulna. 


CHAPTER  XVIII. 

MALFORMATIONS  OF  THE  HAND  EXCEPTING  THE  CONGENITAL 

CONTRACTURES. 

Anomalies  of  development  are  met  with  in  the  hand  as  in  the  foot — - 
namely,  abnormalities  as  to  size  or  number,  either  in  the  direction  of 
hypertrophy  or  deficiency,  and  as  to  position.  Congenital  hypertrophy 
(Ubermass,  Riesenwuchs)  is  more  frequently  limited  to  an  extremity 
than  to  an  entire  body-half,  and  usually  to  the  peripheral  parts  of  the 
hand  or  fingers  (macrocheiria  and  macrodactylia).  The  hypertrophy  may 
involve  all  the  tissues  simultaneously,  or,  what  is  more  frequent,  single 
"systems,"  especially  the  adipose  tissue  (congenital  "soft  elephantiasis 
of  Virchow").  It  may  involve  the  entire  hand  or  preferably  merely 
the  palm  or  single  portions  of  it.  Simultaneous  hyperplasia  of  the 
nerves  and  vessels  (teleangiectasis  and  cavernous  changes  in  the  veins) 
have  been  repeatedly  seen  and  described.  In  a  boy  twelve  years  old 
the  author  saw  a  simultaneous  extensive  hyperplasia  of  the  sweat-glands 
forming  small  tumors.  Whereas  simple  hypertrophy  usually  keeps  pace 
with  the  growth  of  the  rest  of  the  body,  the  forms  complicated  by  con- 
spicuous changes  in  the  vessels  often  develop  rapidly  to  enormous  size, 
like  tumors;  the  former  harmless  variety  is  properly  termed  true  hyper- 
trophy, the  latter  false  hypertrophy.  (See  also  the  corresponding 
description  in  the  section  Malformations  of  the  Foot.)  This  distinction 
is  not  unimportant  in  reference  to  the  prognosis. 

Surgical  interference  is  indicated  for  hypertrophy  only  when  the  use 
of  the  limb  is  compromised.  Wedge-shaped  excisions  usually  have  only 
a  temporary  effect.  The  same  applies  even  more  to  changes  producing 
compression.  How  far  ligation  of  the  main  arteries  can  be  of  service 
has  never  been  subjected,  to  the  author's  knowledge,  to  careful  test. 
In  hypertrophy  inhibiting  the  function  of  single  fingers,  the  member  will 
occasionally  be  removed.  The  entire  hand  will  be  amputated  only  in 
cases  of  general  deformity  with  rapid  upward  advance  of  the  hyper- 
trophy. Such  cases  are  rare;  even  in  this  manner  Fischer  could  not 
check  the  process.  In  false  hypertrophy  more  radical  measures  are 
required;  careful  removal  of  all  tumor-like  tissue  is  then  demanded; 
finally,  amputation  if  the  bone  is  involved. 

Of  more  practical  importance  are  the  conditions  of  "excess"  (Uber- 
zahl),  adhesions,  and  position-anomalies  of  the  fingers  (polydactylia, 
syndactylia,  and  deviations'). 

In  the  entire  series  of  vertebrates  the  extremities  develop  from  the 
lateral  ventral  fold  formed  from  the  primal  vertebral  ridge,  the  Wolffian 
ridge.     In  the  human  species  a  longitudinal  thickening  is  found,  appear- 
(270) 


MALFORMATIONS  OF  THE  HAM). 


271 


ing  at  the  end  of  the  third  week,  which  corresponds  in  the  upper 
extremity  to  the  last  two  cervical  ;ni<l  the  first  two  dorsal  segments. 
At  the  beginning  of  the  fourth  week  of  foetal  life  the  rudiments  of  the 
limbs  are  evidenced  by  round,  knob-like  growths  of  the  mesoblast  of 
the  Wolffian  ridge.  These  spherical  prominences  soon  show  a  pedicle 
separating  them  from  the  trunk.  The  small  pedicle  gradually  stretches 
more  and  more,  and  the  end-piece,  becoming  fin-shaped,  later  forms 
the  hand;  the  pedicle  divides  into  the  upper  arm  and  forearm.  In  the 
fifth  week  five  rays  are  seen  along  the  border  of  the  free  end  of  the 
fin-like  hand-plate,  the  first  divisions  of  the  finger  rudiments.  During 
the  sixth  week  the  indentations  between    the    ring-finger  and  middle 


Fig.  174. 


Fig.  17.-,. 


Fcetal  arm  at  beginning  of  third 
month. 


/Mil 


JL 


QoQ,! 


Fatal  hand  at  beginning  of  fifth  month.    .The  ossi- 
fying parts  are  dark,  the  cartilages  lighter. 


finger  and  between  the  first  finger  and  thumb  deepen  more  than  those 
between  the  other  fingers.  In  about  fifty-four  days  all  the  parts  of  the 
extremities  of  the  human  embryo  are  easily  recognizable.  The  fingers, 
united  up  to  this  time  by  a  web-formation,  separate  from  each  other. 
In  the  third  month  the  development  of  the  matrix  of  the  finger-nails 
is  visible. 

In  the  second  month  the  rudimentary  cartilage  of  the  wrist  differ- 
entiates and  persists  as  such  to  the  time  of  birth.  All  the  bones  of  the 
hand  and  of  the  extremities  are  the  so-called  primordial  bones,  namely, 
a  cartilaginous  preformation.  The  ossification  of  the  phalanges,  notably 
the  end-part  of  the  third  phalanx,  begins  in  the  second  month,  and  at 
the  time  of  birth  the  ossification  of  the  metacarpals  and  phalanges  is 


272 


MALFORMATIONS  OF  THE  HAND. 


found  to  be  complete.  The  large  cartilaginous  epiphyses  ossify  in  the 
second  to  the  third  year  from  special  primary  centres,  and  unite  with 
the  shaft  after  puberty.  The  illustrations  Figs.  174  and  175  show  the 
process  of  ossification  briefly  described. 

"Excess"  of  single  parts  of  the  limbs  is  frequently  seen  in  the  upper 
extremity,  especially  in  the  distal  portion,  the  fingers  (polydactylia), 
whereas  reduplication  of  the  entire  hand  is  a  rarity.  Polydactylia 
usually  involves  only  the  fingers,  rarely  also  the  metacarpals.  As  many 
as  ten  fingers  have  been  seen  (according  to  the  somewhat  unreliable 
reports  of  older  authors,  as  many  as  thirteen).  Heredity  can  often  be 
traced.  The  excess  may  involve  both  sides  symmetrically,  or  the  hand 
and  foot.  Most  often  the  fifth  finger  is  double.  The  supernumerary 
digit  may  approach  a  normal  development  and  articulate  with  the  fifth 
metacarpal,  or  it  may  merely  hang  by  a  thin  pedicle  of  skin. 

Fig.  176. 


Scheme  of  the  various  degrees  of  forking  of  a  digitometacarpal  section. 

On  the  thumb  two  end-phalanges,  discrete  or  united  by  skin,  often 
articulate  with  the  first  phalanx,  the  joint-surface  of  which  shows  two 
pedimental  facets  side  by  side  or  separated  by  a  bony  ridge;  or  both 
end-phalanges  are  confluent  at  the  base  with  a  common  articular 
surface.  This  variety  demands  removal  by  longitudinal  division  of  the 
bone,  the  joint  being  preserved.  Although  less  frequent,  an  analogous 
division  up  to  the  joint  has  been  seen  in  the  little  finger;  incomplete 
cleavage  of  the  end-phalanx  has  never  been  reported. 

"Forked  cleavage"  of  the  finger  sometimes  extends  above  the  end- 
phalanx,  producing  varieties  only  slightly  different  from  the  above  forms. 
A  diagrammatic  series  of  the  forking  up  to  the  proximal  end  of  the 
metacarpal,  sketched  for  the  thumb,  saves  further  description.  (Fig.  176.) 
Figs.  177  and  178  illustrate  forking  of  the  thumb  into  the  metacarpal. 
The  patient,  thirty-five  years  old,  showed  the  same  deformity  in  both 
hands.  The  thumbs  acted  functionally  like  a  small  secondary  hand. 
In  all  varieties  of  polydactylia  the  parallel  double  forms  do  not  show 
svmmetrical  development  in  the  corresponding  sections.  One  of  the 
pieces  of  the  double  formation,  usually  the  one  nearest  to  the  border 
of  the  hand,  is  smaller  and  less  developed  than  the  other,  so  that  after 
its  removal  a  well-developed  hand  remains;  or  both  pieces  are  only 


MALFORMATIONS  OF  THE  WAND. 


273 


rudimentary  or  abnormally  small;  or  the  joints  arc  defective  and  the 
use  of  the  finger  compromised  by  contractures.     Even  in  the  axis  of 


Fit;    177. 


Fig.  178. 


Forking  of  the  thumb  into  the  metacarpal  with  power  in  both  thumbs. 


the  hand  all  sorts  of  variations  in  position  are  seen.    The  same  applies 
to  the  anatomical  findings  in  the  carpal  sections  accompanying  poly- 


Fig.  179. 


Fig.  ISO. 


Microdactylia  with  syndactylia. 
(v.  Bruns.) 


A'-ray  picture  of  Fig.  179. 


dactvlia  and  forking  of  the  metacarpals.    Reduplication  of  the  trapezium, 
excess,   rudimentary  development,   and   fusion   of    several    carpals    in 
Vol.  III.— 18 


274 


MALFORMATIONS  OF  THE  HAND. 


the  distal  row  are  not  infrequent.  The  numerous  variations  in  the 
development  of  the  soft  parts  (skin,  fascia,  ligaments,  tendons,  muscles, 
and  nerves)  covering  the  supernumerary  parts,  have  been  the  subject 
of  many  detailed  reports.  Sometimes  the  part  is  merely  covered  by 
radiations  of  rudimentary  connective  tissue,  more  often  it  is  supplied 
with  tendons  and  short  muscles,  very  rarely  with  accessory  muscles. 

Fig.  181. 


Left  forked  or  cloven  hand. 


Of  less  practical  importance,  but  of  greater  interest  with  reference  to 
the  history  of  evolution,  are  the  deformities  characterized  by  increase  in 
bulk  associated  with  supernumerary  phalanges  (macrodactvlia),  fingers 
with  four,  the  thumb  with  three  phalanges;  and  the  opposite  malforma- 


Fig.  182. 


Right  forked  or  cloven  hand. 


tion  (microdactylia  and  braehydactylia),  characterized  by  deficiency  in  the 
size  of  the  member  and  in  the  number  of  phalanges.  (Figs.  179  and  180.) 
If  the  defect  is  even  greater,  namely,  absence  of  the  finger  or  a  portion 
of  the  hand,  the  condition  is  called  ectrodactylia.  In  one-fourth  of  the 
cases  this  is  associated  with  phocomelia,  hemimelia,  encephalocele,  etc. 


MALFORMATIONS  OF  THE  HAND. 


270 


The  term  "crab-claw  "  or  "cloven-hand  "  is  applied  to  those  deformities 
in  which  the  thumb  and  little  finger  arc  present  and  the  middle  fingers, 
frequently  with  their  metacarpals,  absent.  This  reduction  of  the  hand 
to  two  unequal  halves,  movable  toward  each  other  and  frequently 
apposable,  the  single  parts  of  which  are  inclined  to  be  united  to  each 
other  as  in  syndactylia,  is  usually  inherited,  bilateral  and  symmetrical 
in  all  four  extremities,  as  in  the  case  shown  in  Figs.  181  and  182.  Re- 
cently Perthes  has  discussed  very  convincingly  the  hypothesis  of  origin. 
The  above-mentioned  malformations  are  less  frequent  and  of  less 
practical  importance  than  syndactylia,  which  should  l>e  regarded  not 
as  a  pathological  fusion,  hut  rather  as  the  result  of  arrested  development. 


Fig.  183. 


Fig.  L84. 


-V-ray  picture  of  Fig.  182.      Ectrodactylia, 
symphalangia,  brachydactylia. 


A"-ray  picture  of  Fig.  181.     Microdactylia, 
symphalangia. 


The  process  of  separation  of  the  fingers  normally  completed  at  the  end 
of  the  second  or  beginning  of  the  third  month  is  incomplete  on  account 
of  failure  of  the  skin  to  retract.  According  to  the  level  at  which  this 
takes  place  are  observed  various  degrees  of  syndactylia,  namely,  cuta- 
neous union  involving  one  or  two  phalanges  or  the  entire  finger.  Such 
web-formations  of  skin  are  usually  broader  and  more  yielding  the  fewer 
the  fingers  involved.  The  bridges  of  skin  are  shortest  when  all  the 
fingers  are  involved.  On  surgico-technical  grounds  one  may  classify 
syndactylia  cutanea,  fibrosa,  and  ossea;  in  the  latter  the  nails  are  usually 
fused. 

As  the  fusion  of  the  skin  is  generally  closest  at  the  terminal  pha- 
langes, a  variety  is  seen  in  which  the  syndactylic  union  is  limited  to 


276 


MALFORMATIONS  OF  THE  HAND. 


the  ends  of  the  fingers,  the  more  proximal  parts  being  free;  or  the  union 
may  be  bony  at  the  ends  and  otherwise  cutaneous.  Complete  bony 
union  resembles  defect  of  a  finger.  It  is  more  frequently  seen  in  the 
toes.  It  is  impossible  to  discuss  the  manifold  modifications  here; 
mention  of  the  most  important  will  enable  the  surgeon  to  make  the 
proper  diagnosis  in  most  of  the  cases. 

Operation  is  frequently  necessary  purely  from  an  aesthetic  standpoint, 
in  syndactylia  always  from  a  functional  standpoint.  The  parents  and 
relatives  are  inclined  to  regard  the  malformation  as  unsightly,  and 
at  an  early  date  to  urge  that  the  "  paw-like  "  member  be  made  nor- 


Fig.  186. 


Syndactylia  ossea  (third  phalanx)  with 
eetrodactylia  of  the  third  and  fourth  fin- 
gers, brachydactylia  of  the  thumb,  index 
and  fifth  fingers  and  rudimentary  nails. 


A'-ray  of  case 
after  operation, 
finger  improved. 


Fig.  185  two  and  a  half  years 
Function   of   thumb   and    fifth 


mal.  In  polydactylia  ligation  even  of  pendulous  digits  is  no  longer 
performed;  they  are  either  cut  off  clean  with  the  scissors,  or,  where  the 
supernumerary  fingers  or  phalanges  articulate,  they  are  excised  through 
an  oval  incision.  One  or  two  small  arteries  of  unusual  size  are  some- 
times met  with.  If  possible,  the  incision  should  not  be  on  the  palmar 
surface.  If  the  forking  extends  into  the  shaft  of  the  bone,  the  branch 
should  be  resected  at  its  base.  Where  both  branches  are  rudimentary 
the  removal  of 'one  or  the  other  will  depend  upon  which  branch  gives  the 
better  prospect  of  usefulness  and  in  the  case  of  the  thumb  considers  the 
power  of  adduction.    For  cases  of  divergent  branching  from  the  proximal 


MALFORMATIONS  OF  THE  HAND.  277 

base,  for  example,  at  the  fifth  metacarpal,  in  reduplication  of  the  little 
finger,  if  there  is  a  tendency  to  lateral  deviation  of  one  branch  after 
removal  of  the  other,  Bilhaut's  method,  as  used  and  recommended  by 
Kummel,  may  be  employed:  both  branches  are  freshened  on  the 
adjacent  surfaces  by  means  of  a  Y-shaped  or  Y-shaped  incision,  the 
limbs  of  which  pass  through  the  middle  of  both  nails;  the  branches  are 
apposed  after  removing  the  nails,  and  the  matrices  are  sutured  together. 

The  results  of  surgical  treatment  of  syndactylia  are  not  very  satis- 
factory. The  number  of  methods  extant,  from  the  so-called  method 
of  Celsus  (division  of  the  skin-bridges  to  the  commissure)  to  the  modern 
plastic  Hap  methods  testify  as  to  the  difficulty  of  treatment.  In  all  the 
instances  in  which  primary  union  was  not  obtained  down  to  the  com- 
missure during  childhood  a  tendency  is  seen  to  secondary  adhesion  of 
the  web-like  bridges  of  skin.  All  the  methods  of  tying,  inserting  threads 
or  lead  wire  with  or  without  puncture  at  the  base,  etc.,  are  historical. 
Retraction  of  the  commissure  by  means  of  elastic  bands  after  division 
of  the  bridges,  as  performed  by  Lister,  is  no  longer  applicable.  The 
idea  of  covering  in  the  commissure  at  the  outset  was  first  carried  into 
effect  by  Zeller:  a  dorsal  skin-flap  the  length  of  the  first  phalanx,  with 
its  base  at  the  commissure  and  its  tip  at  the  level  of  the  first  inter- 
phalangeal  joint,  is  sutured  to  the  flexor  surface.  On  account  of  the 
danger  of  necrosis  of  the  tip  Pitha  could  not  endorse  the  method. 
Velpeau  sutured  the  angle  of  the  commissure  directly  together. 

The  method  of  Didot  and  Nelaton  is  much  used :  for  example,  where 
the  third  and  fourth  fingers  are  adherent,  a  wide  dorsal  flap,  wTith  its 
base  on  the  third,  is  freed  from  the  fourth  and  used  to  cover  in  the 
ulnar  side  of  the  third;  a  corresponding  volar  flap  from  the  third  covers 
the  radial  side  of  the  fourth.  The  commissure  is  closed  by  suturing 
the  proximal  edges  of  the  two  flaps.  Where  the  bridge  was  very  small, 
Dieffenbach  turned  down  a  flap  from  the  dorsum  into  the  commissure; 
v.  Langenbeck  covered  in  one  of  the  fingers  by  a  dorsal  and  a  volar 
flap  at  the  commissure,  leaving  the  other  finger  uncovered.  The  width 
of  the  bridge  usually  determines  the  result  of  such  plastic  operations. 
The  author  always  seeks  to  cover  in  the  commissure  accurately,  making 
the  flaps  sufficiently  loose  to  prevent  necrosis.  The  covering  in  of  the 
denuded  areas  appears  to  the  author  to  be  of  secondary  importance. 
This  he  has  accomplished  often  by  direct  suture  of  the  edges,  best  with 
silver  wire;  also  by  the  Didot-Nelaton  lateral  flap  method  where  the 
material  was  sufficient;  also  by  Thiersch  grafts.  Even  primary  suture 
or  grafting  is  not  infrequently  followed,  however,  by  contractures  and 
sensitive  cicatrices.  The  ideal  method  is  the  application  of  pedunculated 
skin-flaps  and  the  avoidance  of  cicatrices  on  the  volar  surface. 

In  conclusion  should  be  mentioned  the  results  of  "ray-defects"  of 
the  upper  extremity,  congenital  anomalies  in  arrangement.  By  ray- 
defects  are  understood  anomalies  depending  upon  the  absence  of  larger 
portions  of  a  "ray,"  namely,  of  one  of  the  morphological  longitudinal 
divisions  of  the  extremity.  If  the  radius  is  partially  or  entirely  absent, 
the  hand  is  displaced  in  a  position  of  radial  abduction  from  the  long 


278 


MALFORMATIONS  OF  THE  HAND. 


axis,  usually  almost  to  a  right  angle.  The  radial  border  of  the  hand 
is  displaced  proximally,  the  skin  of  the  latter  reaching  almost  to  the 
middle  of  the  lower  arm,  the  soft  parts  being  defective.  (Fig.  187.) 
The  defect  is  almost  always  accompanied  by  defects  of  the  thumb  and 
of  the  thenar  eminence.  Ray-defects  of  the  ulna  are  more  rare,  and 
the  anomalies  are  all  correspondingly  in  the  opposite  direction.  The 
inadequacy  of  surgical  measures  liberates  the  author  from  further  dis- 
cussion of  these  and  similar,  rarer  deformities. 


Fig.  187 


Radial  rav-defect,  in  club-hand. 


Genuine  congenital  club-hand  without  defects  gives  better  promise 
of  treatment.  It  is  characterized  by  a  flexion  contracture-position 
(talipomanus  flexa)  with  simultaneous  supination  of  the  normally  devel- 
oped hand  in  ulnar  adduction,  less  frequently  by  a  position  of  extension 
and  pronation.  The  flexion  of  the  fingers  may  be  so  great  as  to  cause 
dorsal  displacement  of  the  phalanges,  especially  in  the  metacarpo- 
phalangeal joints  (author's  observation).  Accompanying  defects  of  single 
carpal  bones  have  also  been  seen.  The  treatment  of  genuine  club-hand 
is  the  same  as  that  of  club-foot:  correction,  immobilization,  exercises, 
massage.  (For  congenital  contractures,  see  section  on  Contractures, 
page  35G.) 


CHAPTER   XIX. 

INJURIES  OF  THE  WRIST  AND  HAND. 
CONTUSIONS  AND  SPRAINS  OF  THE  WRIST. 

All  bloodless  injuries  of  the  wrist  not  included  under  fractures  and 
dislocations  are  classified  as  sprains.  Countless  fractures  of  the  lower  end 
of  the  radius  have  been  diagnosticated  as  sprains  not  only  before  Colles' 
accurate  clinical  definition,  but  even  at  the  present  time.  The  diagnosis 
of  sprain  is  admissible  only  after  careful  exclusion  of  severer  injuries. 
Under  this  heading  are  still  included  a  number  of  lesions  which  would 
be  better  defined  by  the  anatomical  details:  stretching  and  laceration 
of  the  larger  ligaments  or  of  the  synovial  membranes  of  the  individual 
bones  with  secondary  extravasation  in  sections  of  or  in  the  entire  joint; 
laceration  and  avulsion  of  the  tendons;  comminution  and  fissures  of  the 
cartilage,  lacking  the  signs  of  fracture,  but  still  able  to  cause  serious 
lasting  disturbances.  Whereas  contusions  are  generally  caused  by  direct 
violence,  sprains  may  result  from  forced  rotary  movements,  pronation 
and  supination,  flexion,  extension,  and  radial  and  ulnar  adduction. 
The  mechanism  may  vary  as  greatly  as  the  movements  of  the  hand  at 
the  wrist.     Frequently  contusion  and  sprain  are  combined. 

The  transverse  ligament  is  usually  torn  slightly  by  the  extension  of 
the  hand.  Pain  is  elicited  by  pressure  at  the  attachments  on  the  pisiform, 
trapezium,  and  scaphoid.  At  the  same  time  the  flexor  tendons  and 
sheaths  are  sprained,  as  indicated  by  the  pain  on  flexing  the  fingers  and 
by  the  effusion  in  the  tendon-sheaths.  The  synovial  sacs  on  the 
volar  side  of  the  joints  may  be  stretched,  the  dorsal  edges  of  the  cartilages 
of  the  wrist  bones  may  be  bruised  by  the  pressure,  and  the  injury  start- 
ing on  the  volar  side  may  be  evidenced  simultaneously  by  points  of 
tenderness  on  the  dorsum.  Although  not  belonging  here  in  the  strict 
anatomical  sense,  a  slight  chipping  off  of  the  cartilage  may  occur  and 
exist  for  some  time  under  the  diagnosis  of  sprain  or  contusion,  and 
influence  the  later  course  of  the  contusion.  Dislocation  and  avulsion 
of  the  tendons  will  be  considered  separately. 

In  like  manner  contusion  or  sprain  on  the  dorsum  may  be  due  to 
transmission  of  the  force  causing  the  injury  on  the  flexor  side;  chipping 
off  of  the  bone  or  cartilage  of  the  carpus  or  metacarpus  is  not  infrequent. 
By  forced  radial  adduction  the  capsule  of  the  wrist  may  be  torn  on  the 
ulnar  side,  by  forced  ulnar  adduction  on  the  radial  side.  In  the  first 
instance  the  sheath  of  the  extensor  carpi  ulnaris,  in  the  second  those 
of  the  extensor  pollicis  brevis  and  abductor  pollicis  longus,  or  the 
muscles  themselves,  may  be  torn.     In  the  one  case  there  may  be  slight 

(  279  ) 


280  INJURIES  OF  THE  WRIST  AND  HAND. 

tear-fractures  of  the  styloid  process  of  the  ulna,  in  the  other  of  the  same 
process  of  the  radius. 

A  complication  of  sprain  by  supination,  important  and  yet  easily 
overlooked,  is  the  tearing  of  the  capsule  of  the  radio-ulnar  joint,  with 
or  without  injury — displacement — of  the  articular  disk;  the  result  may 
be  protracted  impairment  of  supination  and  pronation,  and  incomplete 
recovery.  Forced  pronation  may  tear  the  extensor  carpi  radialis  longus. 
The  same  muscle  is  found  frequently  involved  in  flexion-sprain  and 
contusion  of  the  dorsum,  the  first  evidence  of  which  is  a  distinct  point 
of  tenderness  on  pressure  at  its  attachment  on  the  second  metacarpal. 
In  like  manner  in  sprain  by  extension  with  direct  injury  of  the  flexor 
carpi  radialis,  the  same  tenderness  on  pressure  is  found  at  the  attach- 
ment of  the  muscle  on  the  base  of  the  same  bone.  Extravasation  in  the 
wrist-joint  is  frequently  found  accompanying  the  above  injuries,  and  is 
recognizable  by  the  fact  that  it  pushes  up  the  dorsal  tendons,  causes 
bulging,  and  gives  fluctuation  of  the  capsule  at  both  sides  of  the  tendons. 

Diagnosis  — The  diagnosis  depends  upon  careful  palpation  and  the 
exclusion  of  severer  injuries.  The  points  of  tenderness  obtained  by 
testing  the  function  and  by  pressure  are  usually  accurate  guides.  The 
changes  are  often  quickly  recognized  by  comparing  with  the  sound 
hand.  A  suspected  fissure  or  slight  chipping  off  of  bone  may  be  only 
recognizable  by  means  of  the  .r-ray. 

Treatment. — Slight  sprains  without  palpable  changes  merely  require 
protection,  subsequently  massage  and  judicious  use.  All  severe  sprains 
require  immobilization.  The  joint  as  well  as  the  sprained  or  partially 
torn  ligaments  require  fixation;  the  pain  diminishes  rapidly.  Union 
of  the  ligaments  and  complete  restoration  of  function  are  best  assured 
by  a  position  opposite  to  the  direction  of  the  violence,  namely, 
in  sprains  by  extension  in  the  flexed  position.  Without  exception 
the  author  uses  pasteboard-strip  splints  or  thin  plaster-strip  splints 
moulded  to  the  arm,  the  technic  of  applying  which  will  be  de- 
scribed under  Fractures  of  the  Radius.  By  this  means  all  secondary 
loosening  of  the  ligaments,  which  is  less  to  be  feared  in  the  wrist  than, 
in  the  ankle,  is  best  prevented,  and  the  exudation  in  the  tendon-sheaths 
has  a  correspondingly  larger  space  so  that  the  return  of  function  is 
quicker  and  less  painful.  Aspiration  of  the  joint  will  seldom  be  necessary. 
Old  sprains  and  contusions  and  their  sequeke — ankylosis  of  the  tendons 
and  sensitiveness  in  movements  of  the  joint — require  passive  movements, 
exercise  and  massage,  baths,  hot  compresses  or  the  hot-air  apparatus. 
Occasionally  in  treating  "old"  sprains  one  finds  a  lesion  of  greater  im- 
portance than  is  conveyed  in  the  concept  "  sprain."  In  such  instances  the 
manipulation  leads  to  better  recognition  and  indicates  the  use  of  knife 
or  chisel. 

ISOLATED  INJURIES  OF  THE  TENDONS. 

Dislocation   of  the   Tendons. — A  traumatic  displacement .  of    the 

tendons  of  the  hand  and  fingers  comparable  in  importance  to  displace- 


ISOLATED  INJURIES  OF  THE  TENDONS.  281 

ment  of  the  tendons  of  the  peronei  in  the  foot  is  unknown.  Displace- 
ments of  the  tendons,  however,  frequently  accompany  fracture  and 
dislocation  of  the  hones,  and  their  reposition  goes  hand  in  hand  with 
the  treatment  of  these  injuries. 

In  a  number  of  instances  of  dislocation  of  the  thumb  there  has  been 
lateral  displacement — and  hooking — of  the  tendon  of  the  flexor  longus 
pollicis.  Helferich  especially  has  called  attention  to  this  hindrance  to 
reposition.  The  tendon  in  question  slips  over  the  neck  of  the  first 
metacarpal,  which  latter  in  forced  lateral  displacement  of  the  joint- 
surface  holds  the  tendon  back  like  a  hook.  The  displacement  can 
often  be  overcome  by  strong  ulnar  inflexion  of  the  first  phalanx  of  the 
thumb.  In  old  contractures  the  tendons  are  often  found  displaced  later- 
ally. Further,  one  should  remember  the  ulnar  displacement  of  the  ex- 
tensors in  arthritis  deformans  of  the  metacarpophalangeal  joints.  In 
cases  of  habitual  dislocation,  as  in  dislocation  of  the  first  metacarpal 
on  its  carpal  or  of  the  first  phalanx  on  its  metacarpal,  a  lateral  dis- 
placement of  the  tendon,  usually  to  the  ulnar  side,  occurs  at  the  time  of 
dislocation. 

Division  of  the  Tendons  in  the  Hand  and  Fingers. — Subcutaneous 
laceration  of  the  tendons,  more  properly  avulsion  of  the  tendons,  is  of 
rare  occurrence  in  the  hand,  and  more  commonly  affects  the  extensors 
than  the  flexors.    Of  the  latter,  few  cases  have  been  reported. 

In  the  case  of  an  extensor  the  avulsion  takes  place  close  to  the 
insertion;  owing  to  its  partial  fixation  at  the  joint  this  tendon  does  not 
retract;  it  is  usually  held  attached  to  the  end-phalanx  by  several  lateral 
fibres.  A  small  piece  of  bone  is  often  torn  from  the  base  of  the  end- 
phalanx  with  it.  The  production  of  the  injury  presupposes  maximal 
flexion  of  the  end-phalanx  with  extension  of  the  second  phalanx  at  the 
first  interphalangeal  joint.  Suture  is  advisable  for  complete  division; 
where  the  tendon  is  held  laterally,  immobilization  of  the  end-phalanx 
in  extension  may  conduce  to  the  formation  of  fibrous  union,  but  the 
restoration  of  function  is  seldom  complete. 

In  the  much  rarer  subcutaneous  laceration  of  the  flexors  a  small 
fragment  of  bone  is  almost  always  torn  off  from  the  base  of  the  end- 
phalanx.  The  injury  is  caused  by  active  muscular  contraction  simul- 
taneous with  passive  hyperextension.  Owing  to  its  lack  of  fixation  the 
flexor  tendon  retracts  much  further  and  forms  higher  up  a  palpable 
tender  lump  accompanied  by  loss  of  function.  The  treatment  of  this 
injury  is  much  less  favorable.  The  attempt  to  force  the  tendon  down 
by  bandaging  the  muscles  of  the  forearm  is  usually  futile;  even  suture 
is  uncertain  if  the  tendon  is  no  longer  held  by  lateral  fibres.  Still,  these 
measures  should  always  be  tried  or  supplemented  by  plastic  operation. 
In  a  case  of  Sick's  the  proximal  stump  was  so  turned  upon  itself  that 
suture  was  impossible. 

Direct  subcutaneous  division  of  the  tendon  without  other  injuries 
can  only  happen'  in  consequence  of  very  great  violence  produced  by  a 
blunt  object  without  division  of  the  skin.  Very  little  has  been  reported 
in  regard  to  such  injuries,  yet  the  functional  loss  resulting  from  the 


282  INJURIES  OF  THE  WRIST  AND  HAND. 

injury  being  overlooked  and  remaining  uncorrected  is  lamentable  with 
reference  to  the  earning  ability  of  the  patient. 

According  to  the  recent  observations  of  military  surgeons  (Diims, 
Steudel ) ,  it  would  seem  that  the  cases  of  pronounced  functional  disturb- 
ance of  the  extensor  longus  pollieis  tendon  known  as  "drummers'  par- 
alvsis  "  are  due  to  rupture  of  the  tendon.  The  affection,  beginning  with 
the  symptoms  of  tenosynovitis,  causes  destructive  inflammatory  changes 
in  the  tendon;  a  single  sharp  muscular  contraction  suffices  to  tear  the 
loosened  tendon.  In  1881  Roberts  reported  such  a  case  of  genuine 
rupture;  Diims  has  seen  2  cases,  and  Steudel  proved  the  existence  of 
rupture  on  operating.  The  site  of  rupture  is  always  the  point  at  which 
the  tendon-sheath  emerges  from  the  distal  border  of  the  dorsal  trans- 
verse carpal  ligament.  It  cannot  be  denied  that  this  circumstance 
is  significant,  considering  the  duration  of  the  irritation  and  the  very 
exacting,  almost  spasmodic  use  of  this  tendon  in  holding  the  drumstick. 
It  is  evident  that  if  the  correctness  of  this  discovery  can  be  verified,  the 
onlv  treatment  of  this  "paralysis"  is  suture  of  the  tendon. 

Open  Division  of  the  Tendons. — The  author  regards  it  as  practical  to 
describe  this  injury  in  connection  with  the  technic  of  treatment,  although 
naturally  it  is  very  frequently  only  a  part  of  simple  or  complicated 
injuries  of  the  hand  and  fingers. 

Division  of  the  tendons  usually  results  from  incised  or  stab- wounds; 
the  diagnosis  is  frequently  made  by  the  patient  and  it  is  not  unusual 
for  the  latter  to  appear  and  state  that  the  wound  had  been  sewed  up,  but 
that  he  cannot  move  the  end  of  his  finger,  so  that  the  "bender"  must 
be  hurt,  whereas  the  tendon  had  never  been  sutured.  With  proper 
attention  it  is  hardly  possible  to  overlook  this  important  injury,  if  before 
beginning  treatment  every  case  is  examined  systematically  in  regard  to 
function,  circulation,  and  nerve-supply.  The  excuse  that  the  extreme 
pain  prevented  examination  is  invalid,  for  even  children  can  be  made 
to  attempt  voluntary  movements.  On  the  other  hand,  division  caused  by 
stab-wounds,  by  metal  or  glass,  particularly  if  the  wound  is  small,  may 
be  regarded  by  the  patient  as  too  slight  to  require  surgical  assistance,  and 
be  first  recognized  on  attempting  to  use  the  hand  or  fingers.  Individuals 
with  an  occupation  demanding  fine  finger-work  are  wont  to  seek  infor- 
mation at  once  in  regard  to  the  seriousness  of  the  injury,  whereas  others 
— servants — with  equal  frequency  are  indifferent  about  the  injury  for 
weeks,  particularly  if  it  involves  one  of  the  fingers  of  the  ulnar  border, 
fourth  or  fifth.  Partial  division  of  the  tendons  is  easily  overlooked;  its 
functional  significance  is  also  slight.  There  is  usually  very  little  dis- 
turbance except  that  of  diminished  power. 

Treatment. — In  general  the  following  important  principles  are  to  be 
observed:  1.  If  the  stumps  of  the  tendons  are  soiled,  they  should  either 
be  cleaned  up  or  the  wound  kept  open  for  a  few  days  until  the  question 
of  infection  and  its  severity  is  determined.  2.  Where  there  is  extensive 
laceration  of  the  tendons  and  plastic  measures  are  required  to  overcome 
the  defects,  the  operation  should  not  be  done  at  first,  but  after  the  wound 
has  healed.     Plastic  operations  performed  after  months  usually  give 


ISOLATED  INJURIES  OF  THE  TENDONS.  283 

primary  union  and  better  results.  3.  If  the  proximal  stump  must  be 
found,  it  is  advisable  to  stroke  the  muscle  forcibly  downward,  excep- 
tionally to  bandage  the  muscles  of  the  forearm  downward  as  proposed  by 
Rose,  aided  by  Feli/.et's  hook  if  the  surgeon  is  dealing  with  the  flexors, 
or  to  hyperextend  strongly  the  adjacent  lingers,  by  which  the  proximal 
stump  is  pulled  down.  4.  If  the  stump  is  widely  retracted,  prolongation 
of  the  wound  in  the  direction  of  the  tendon  is  the  quickest  and  most 
certain  way  of  reaching  it.  It  should  not  be  torn  or  lacerated,  but  tied 
with  a  loop  of  thread,  which  latter  may  be  used  for  suture.  5.  The 
technic  should  be  simple;  the  suture  material  should  be  of  small  size 
and  coaptate  the  surfaces  of  the  tendon  without  impairing  the  circu- 
lation. In  pulling  upon  the  sutures  the  hand  and  fingers  should  be 
held  in  the  position  which  relaxes  the  tendon.  The  wound  may  be 
closed,  or  small  openings  left  with  thin  aseptic  drains  according  to  the 
danger  of  infection.  6.  The  splint  should  insure  immobilization  for 
three  weeks.  The  position  should  be  as  comfortable  as  possible  for  the 
patient;  for  example,  flexion  of  the  middle  finger  with  extension  of  the 
second  and  fourth  cannot  be  endured  very  long,  therefore  better  all 
fingers  flexed.  7.  In  general,  passive  motion  should  not  be  begun  before 
the  end  of  the  third  week.  Massage  of  the  muscles  of  the  forearm  during 
this  time  is  superfluous,  and  on  account  of  the  unrest  of  the  patient 
jeopardizes  the  result.  Modifications  in  individual  cases  are  self- 
evident. 

In  describing  the  injuries  of  the  tendons  the  author  desires  to  make 
clear  the  indications  for  treatment  because'  of  the  social  significance  of 
this  injury  with  regard  to  the  impairment  of  the  earning-efficiency,  and, 
further,  because  every  surgeon  should  be  in  a  position  to  carry  out  the 
technic  even  with  limited  assistance.  If  injury  of  the  tendons  is  diag- 
nosticated, but  the  technical  conditions  for  its  treatment  not  available, 
the  author  would  recommend  as  most  profitable  to  the  patient  that  the 
wound  be  covered — after  ligating  the  bleeding  vessels — with  an  aseptic 
dressing  that  will  not  smear  the  wound  area  and  that  the  patient  be  re- 
ferred to  an  institution  where  skilful  technic  can  be  guaranteed,  for 
inadequate  treatment  is  often  more  dangerous  and  productive  of  more 
harm  than  failure  to  suture  with  the  possibility  of  subsequent  careful 
measures. 

The  author  employs  the  following  technic:  If  the  wound  is  large  or 
several  tendons  involved,  the  patient  is  anaesthetized.  On  psychical 
grounds  this  is  often  better  and  usually  guarantees  greater  care  in  all 
the  details,  as  rapidity  is  not  imperative.  If  the  wound  is  slight,  local 
anaesthesia  may  be  employed.  The  region  about  the  wound  is  cleaned 
in  the  usual  manner  and  the  skin  sterilized  with  extreme  care,  a  tiresome 
undertaking  of  twenty  to  thirtv  minutes  in  the  case  of  laborers.  Accord- 
ing  to  the  amount  of  bleeding — in  fact,  in  the  majority  of  cases — the 
Esmarch  bandage  is  applied.  The  proximal  stump  can  usually  be  drawn 
down  by  holding  the  hand  and  arm  in  the  appropriate  position  and 
stroking  the  muscles  downward.  The  bandage  will  rarely  be  required. 
After  cleansing  the  wound  and  ligating,  the  proximal  stump  is  transfixed 


284 


INJURIES  OF  THE  WRIST  AND  HAND. 


T3^  inch  above  the  cut  surface  with  a  Hagedorn  needle — and  in  the 
author's  clinic  without  exception  with  silk  suture — and  the  tendon 
held  loosely  by  this  thread.  (Fig.  190,  a.)  In  the  manipulation  the 
tendon  is  held  carefully  with  tendon-forceps  or  a  tenaculum  (Figs. 
18S  and  189);  the  silk  is  passed  in  the  same  plane  through  the  distal 


Fig.   1S8. 


c 


Tenaculum. 


stump  and  the  suture  left  untied.  A  second  suture  is  then  passed 
perpendicular  to  the  former  \  inch  from  the  edge  through  both  stumps; 
thread  a  is  then  tied,  then  thread  b  somewhat  looser  to  avoid  displacing 
the  apposed  surfaces.    One  suture  is  usually  sufficient  for  small  tendons, 


Fig.  189. 


Tendon  forceps. 

in  which  case  the  author  sutures  a  little  farther  from  the  end,  about 
j5g-  inch.  This  suture  is  simple,  quickly  performed,  and  certain.  If  it 
is  necessary  to  freshen  the  tendons  the  author  always  cuts  them  squarely 
off,  never  obliquely;  he  never  affixes  to  the  adjacent  tissues.    As  stated, 

Fig.   190. 


Tendon  suture. 


the  wound  is  always  closed  primarily  if  possible,  or  small  drains  left 
between  the  skin  sutures  if  necessary;  it  is  never  left  open,  rarely  drained 
from  the  bottom.  The  author  always  uses  three-ply  twisted  English 
silk — No.  00-1.  Primary  union  without  ejection  of  "aseptic"  threads 
was  obtained  in  15  cases,  in  each  of  which  several  tendons  were  sutured. 


ISOLATED  INJURIES  OE  THE  TENDONS. 


285 


Three  cases  of  plastic  flap  operation  were  equally  successful.  Numerous 
instances  of  suture  of  single  tendons  gave  like  results.  No  mention 
of  or  apology  for  the  occasional  infection  accompanying  the  injury  is 
needed.  Many  infections  can  be  checked  by  inserting  several  small 
drains  between  the  skin  sutures. 

Immobilization  for  flexor  injuries  is  always  by  means  of  a  moulded, 
well-padded  plaster  splint  applied  on  the  dorsum  with  the  hand  flexed; 
by  means  of  straight  pasteboard  splints  for  injuries  of  the  extensors;  by 
means  of  a  plaster  strip  moulded  on  the  flexor  surface  with  marked 

Fig.  192. 


Tendon  suture  methods:  a,  Wiilner;  b,  Hagler;  c-f,  Trnka. 


dorsal  flexion  of  the  hand  if  all  the  extensors  are  involved.  It  is  an 
operation  which  the  author  likes  to  perform  without  assistance — with 
the  exception  of  the  anresthetizer — before  students.  If  infection  occurs, 
the  skin  suture  should  be  loosened;  the  result  of  the  tendon  suture  is 
thereby  almost  always  jeopardized.  If  recovery  is  uninterrupted,  the 
first  bandage  is  changed  on  the  tenth  to  the  fourteenth  day.  The  author 
has  often  allowed  it  to  remain  until  the  third  week.  He  never  begins 
massage,  passive  motion,  etc.,  until  the  end  of  the  third  week,  for  few 
cicatrices  are  under  such  unfavorable  circumstances  for  holding  as  those 
of  the  tendons — slow  proliferation  of  connective  tissue,  scant  formation 


230  INJURIES  OF  THE  WRIST  ASD  HAND. 

of  vessels,  constant  traction.  At  the  end  of  this  time  motion  may  be 
begun  and  massage  adjacent  to  the  wound,  electricity  and  massage 
applied  to  the  corresponding  muscles,  and  after  four  weeks  active 
motion  begun.  For  division  of  all  the  flexors  and  extensors,  the  author 
prefers  absolute  immobilization  for  five  weeks  with  the  chance  of 
adhesions,  the  latter  often  being  entirely  overcome  by  prolonged 
treatment. 

The  author  should  not  omit  to  mention  the  methods  of  treatment 
used  elsewhere.  Xicoladoni  recommends  drawing  down  the  proximal 
stump  with  a  tenaculum.  This  method  does  not  always  give  the  desired 
result,  sometimes  produces  secondary  injuries,  especially  of  the  tendon- 
sheaths,  and  may  tear  out  the  tendon  or  fray  out  the  stump.  Madelung 
proposed  to  hunt  for  the  retracted  stump  through  an  incision  proximal  to 
the  wound,  to  slip  a  loop  of  thread  over  the  stump  and  draw  the  former 
into  the  wound  with  a  probe.  If  the  tendon  is  found,  subsequent  prolon- 
gation of  the  wound  is  unnecessary,  an  unmistakable  advantage  in  appro- 
priate cases.  The  prolonged  incision  necessary  to  reach  the  proximal 
stump  is  made  by  Witzel  at  the  side  of  and  parallel  to  the  tendon,  to 
prevent  the  suture-line  from  lying  upon  the  tendon  suture.  This  propo- 
sition is  founded  upon  the  fact,  reported  from  Billroth's  clinic  by 
Schussler,  that  the  wounds  are  often  under  great  tension  on  account  of 
the  necessary  immobilization,  as  the  result  of  which  transverse  wounds 
are  usually  (edematous;  so  that,  even  where  the  course  is  smooth,  con- 
siderable cicatricial  tissue  is  formed  and  extends  to  the  tendon.  Whether 
this  can  be  obviated  by  a  lateral  incision  remains  undetermined.  Special 
fixation  measures — provisory  suture  of  the  tendons  (Xicoladoni),  fixa- 
tion sling  (Witzel) — are  hardly  necessary.  The  most  important  details 
of  the  teehnic  are  those  given  by  Wolfler,  Tmka,  and  Hagler,  as  shown 
in  Fig.  192.     For  plastic  operations  on  the  tendons,  see  page  37o. 


FRACTURES  OF  THE  LOWER  END  OF  THE  RADIUS. 

Fracture  at  the  Classical  Spot;   Typical  Fracture  of   the  Radius; 

Colles'  Fracture. 

Fractures  at  the  junction  of  the  middle  and  lower  thirds  are  not  much 
more  frequent  than  those  of  the  middle  or  upper  third.  They  were 
described  in  Chapter  XIV. 

The  so-called  "typical"  fracture  of  the  radius  has  quite  another 
practical  importance.  The  more  closely  it  is  studied,  the  more  the  idea 
of  "typical,"  at  least  with  reference  to  the  anatomy,  disappears.  The 
details  of  the  fracture  are  manifold,  and  the  typical  repetition  of  the 
variety  is  lacking  in  a  large  number  of  cases  which  are  classified  clini- 
cally as  "typical"  fractures.  Xevertheless  the  symptom-complex  with 
reference  to  the  etiology  and  clinical  course  of  the  injury  has  repeatedly 
so  much  in  common  that  it  is  advisable  on  practical  grounds  to  retain 
the  chosen  term.     (Colles,  v.  Volkmann.) 


FRACTURES  OF  THE  LOWER  END  OF  THE  RADIUS.        287 

The  history  of  the  injury  is  rich  in  interesting  details.  It  is  a  curious 
circumstance  that  it  was  almost  unknown  at  tlu-  beginning  of  the 
nineteenth  century,  so  that  Colles,  the  Scotch  surgeon,  was  able  to 
publish  the  first  accurate  report  in  L814.  As  a  result  the  names  of 
distinguished  German,  French,  English,  and  American  surgeons  are 
found  connected  with  the  pathology  and  treatment  of  fracture  of  the 
radius,  a  good  illustration  of  its  great  practical  importance.  As  fracture 
of  the  radius  takes  first  place  in  frequency  among  all  fractures  of  the 
hones,  according  to  Goyrand  almost  a  third,  according  to  Malgaigne 
10  per  cent.,  according  to  v.  Brims  (.U'>  per  cent.,  and  its  significance  with 
reference  to  the  use  of  the  hand  is  so  evident,  it  would  he  idle  to  waste 
further  words  in  regard  to  it.  By  the  introduction  of  the  accident  laws 
in  Germany  it  has  acquired  an  especial  prognostic  position.  The  treat- 
ment may  present  such  difficulties  and  annoyances,  even  where  all  details 
are  carefully  regarded,  that  often  only  inexperience  can  excuse  rash 
criticism  of  the  results  accomplished  by  others  that  is  made  without  accu- 
rate knowledge  of  the  relations  appertaining  to  each  individual  case. 
The  injury,  to  anticipate,  is  by  no  means  to  be  regarded  as  harmless 
as  it  appears  from  many  representations,  particularly  in  old  age,  so  that 
it  seems  to  us  to  be  a  special  duty  to  discuss  not  only  all  the  derails  of 
the  recent  injury  with  respect  to  the  therapeutic  indications,  tat  also 
the  diverse  modifications  of  the  prognosis. 

By  typical  fracture  of  the  radius — loco  classico — is  understood  an 
isolated  fracture  of  the  bone,  usually  transverse,  about  f  to  4  inch  above 
its  distal  end,  with  displacement  of  the  distal  fragment  backward  and 
usually  outward,  and  frequently  with  corresponding  displacement  of 
the  wrist.  It  almost  always  results  from  a  fall  upon  the  volar  surface 
of  the  outstretched  extended  hand. 

Mechanism  of  Origin. — The  clinical  symptoms  can  be  grasped  most 
rapidly  if  the  mechanism  of  origin  is  considered. 

The  possibility  of  producing  a  fracture  in  a  long  bone  is  known  to 
increase  with  the  distance  of  the  lines  of  direction  of  the  forces  from  the 
bone  (a  generally  applicable  law  of  fracture).  The  forces  concerned  in 
fracture  of  the  radius  are  as  follows:  by  falling  upon  the  palm  of  the 
extended  hand,  the  carpus,  by  reason  of  the  solidity  given  by  its  liga- 
ments, is  pushed  as  a  solid  body  against  the  posterior  edge  of  the  radius. 
The  force  exerted  by  the  counteraction  of  the  ground  against  that  part 
of  the  weight  of  the  body  thrown  upon  the  wrist  is  transmitted  to  the 
carpus,  which  in  turn,  as  a  solid,  unyielding  mass,  transmits  this  force 
undiminished  to  the  radius.  Resistance  of  the  ground,  part  of  the 
body-weight,  velocity  of  the  falling  motion,  are  the  components  of  this 
first  force.  Simultaneously  the  firm  anterior  ligament1  is  put  on  the 
stretch,  which,  after  exhaustion  of  its  'physiological  elasticity,  opposes 

1  According  to  Henle.  the  ligamentum  carpi  volare  profundum  arcuatum,  radiatum,  and  trans- 
versum;  according  to  the  more  recent  nomenclature  (W.  His,  "Die  anatomische  Nomenclatur," 
Archiv  f.  Anat.  u.  Physiologic  Supplement  band  1895,  p.  42)  ligamentum  radiocarpeum  volare 
which  spreads  out  from  the  styloid  process  and  anterior  margin  of  the  carpal  articular  surface 
of  the  radius  into  several  bands  running  to  the  scaphoid,  lunar,  cuneiform,  and  os   magnum. 


288 


INJ CRIES  OF  THE  WRIST  AND  HAND. 


Fig.  193. 


the  first  force  specified  above  by  pulling  upon  the  radius.  It  is  more 
resistant  than  the  bone,  so  that  the  latter  breaks  more  easily  than  the 
ligament  tears.  The  lower  end  of  the  radius  is  therefore  broken  off  by 
pressure  and  by  traction.  (Fig.  193.)  The  exclusive  action  of  a  blow 
or  a  tear  is  usually  out  of  question;  considered  mechanically,  both  forces 
must  act  to  produce  the  fracture. 

The  effect  of  the  force  is  the  same  whether  a  body  is  set  in  motion  or 
a  moving  body  is  arrested;  in  both  cases  the  possibility  of  a  solution  of 

continuity  increases  with  the  velocity. 
The  same  force  could  be  applied  to 
the  radius  without  producing  frac- 
ture, if  the  increase  were  gradual. 
The  velocity  in  falling  is  accordingly 
of  great  importance,  but  it  is  rarely 
possible  to  form  an  accurate  judg- 
ment in  regard  to  it.  In  like  manner 
the  velocity  with  which  the  force  is 
transmitted  determines  the  site  at 
which  the  force  is  manifested:  the 
more  rapid  the  transmission,  the 
closer  to  the  point  of  application  will 
be  the  effect  of  the  force.  That  the 
fracture  can  result  in  the  distal  end 
of  the  radius  and  not  at  its  middle 
is  explained  by  purely  mechanical 
laws,  the  analysis  of  which  is  beyond 
the  scope  of  the  present  description. 
In  falling,  the  patient  unconsciously 
pronates  the  radius  more  or  less  for- 
cibly to  support  himself.  Whether 
the  fragment,  in  being  displaced 
backward,  will  be  pushed  at  the  same 
time  laterally  (usually  outward),  will 
depend  upon  the  degree  of  pronation 
at  the  moment  ;  the  fragment  will 
sometimes  be  arrested  in  semipronation  by  the  contact  of  the  hand  with 
the  ground,  and  the  resistance  of  the  same,  while  the  radius  is  still 
further  pronated — i.  c,  the  lower  fragment  is  forced  against  the  upper 
in  supination. 

Backward  displacement,  usually  accompanied  by  shortening  of  the 
dorsal  axis  of  the  radius,  and  slight  lateral  displacement  of  the  lower 
fragment  necessarily  produce  lateral  deviation  of  the  wrist  and  hand, 
generally  abduction  (radial  inflexion). 

From  the  above  description  it  is  easy  to  understand  how  the  continua- 
tion of  the  force  at  the  moment  of  fracture  can  produce  impaction  of  the 
fragments  in  a  large  number  of  cases;  the  shaft  of  the  radius  is  forced 
farther  forward  and  displaced  against  the  lower  fragment  as  the  latter 
slips  backward,  so  that  its  posterior  edge  is  impacted  against  the  anterior 


Typical    fracture    of    the   radius.      Backward 
displacement  of  the  lower  fragment. 


FRACTURES  OF  THE  LOWER  END  OF  Till-:  HAD  lis.        289 

edge  of  the  fragment.  By  a  fall  upon  the  dorsum  of  the  Hexed  hand 
— therefore  with  the  hand  in  the  opposite  position — the  forces  mentioned 

work  in  the  opposite  direction.  In  this  case  the  posterior  ligamenl 
assumes  the  role  played  by  the  anterior  in  the  typical  fracture  and  pulls 

upon  the  posterior  edge  of  the  lower  border  of  the  radius,  while  the  carpal 
bones  press  against  the  anterior  edge  and  transmit  the  blow.  The 
fracture-line  runs  in  a  characteristic  manner  in  the  opposite  direction, 
distal-dorsal  to  proximal-volar.  The  distal  fragment  is  displaced  for- 
ward correspondingly  if  displacement  occurs,  and  pushes  the  upper 
fragment  backward.  As  in  this  fracture  the  effect  of  the  effort  to  gain 
the  support  of  the  forearm  is  absent,  there  is  no  movement  of  pronation; 
the  blow  overcomes  the  flexion  and  impaction  results  almost  without 
exception  (not  infrequently  with  comminution). 

Anatomical  Findings. — The  above  mechanical  factors  produce  the 
typical  fracture  of  the  radius.  The  anatomical  findings  on  autopsy  and 
operation  give  less  information  than  examination  on  the  living  subject; 
the  recent  contributions  of  the  x-ray  and  of  experiments  have  been 
valuable.  Kahleyss  and  Oberst  have  carefully  sketched  a  composite 
picture  of  the  injury  as  filled  out  by  the  a,- ray.  For  the  anatomical 
description  it  is  practical  to  distinguish  from  a  therapeutic  and  prog- 
nostic point  of  view  separation  at  the  epiphysis,  complete  and  incomplete 
fracture  and  fissures  (the  so-called  typical  contusion).  It  is  not  correct 
to  designate  the  fracture  simply  as  an  epiphyseal  fracture.  A  pure 
separation  of  the  epiphysis  is  not  seen  after  the  eighteenth  year,  whereas 
the  greater  number  of  injuries  occur  between  the  fiftieth  and  sixtieth 
years.  Separation  of  the  epiphysis  in  children  is  not  rare.  (Helferich.) 
The  fracture-line  almost  always  begins  at  the  epiphyseal  line  on  the 
flexor  side,  follows  the  line  for  a  short  distance  and  then  runs  obliquely 
through  the  shaft  to  the  posterior  surface,  so  that  a  larger  or  smaller 
jagged  fragment  of  the  shaft  is  attached  to  the  edge  of  the  epiphysis, 
usually  widest  toward  the  posterior  surface.  (Kahleyss-Oberst.)  How  far 
the  periosteum  is  separated  from  the  epiphysis,  as  cited  by  v.  Bruns,  can 
hardly  be  determined  by  palpation.  O.  Wolff  regards  pure  epiphyseal 
separation  confined  sharply  to  the  line  of  growth  as  the  rule.  The  frac- 
ture-line is  commonly  extra-articular  and  lies  \  (Smith)  to  H  (Colles, 
Hamilton)  inches,  usually  f  to  1\  inches  (Dupuytren,  Konig),  above  the 
point  of  the  styloid  process.  (Fig.  194.)  The  more  recent  investigations 
with  the  x-ray  indicate  that  it  is  between  §  and  £  inch.  Bardenheuer 
states  rightly  that  this  distance  varies  within  rather  wide  limits,  according 
to  the  side  on  which  the  fracture  is  examined  and  with  the  obliquity  of  the 
fracture-line.  The  distance  from  the  joint  is  usually  less  on  the  anterior 
than  on  the  posterior  surface,  namely,  the  surgeon  is  dealing  with  a 
fracture-line  running  obliquely,  distal-volar  to  proximal-dorsal.  For 
the  reversed  fracture-line  caused  by  falls  upon  the  dorsum,  see  the  latter 
part  of  the  section  on  Mechanism  of  Origin. 

If  the  distal  fragment  is  displaced,  it  may  be  pushed  backward  and 
upward  in  the  direction  of  the  shaft;  or,  it  may  be  rotated  backward 
about  its  radio-ulnar  axis.  It  is  frequently  displaced  outward  at  the 
Vol.  III.— 19 


290 


INJURIES  OF  THE  WRIST  AND  HAND. 


same  time.  If  the  ulna  is  uninjured,  the  hand  is  abducted  at  the  wrist 
(radial  inflexion).  (Fig.  196.)  If  the  fragment  is  held  by  the  cartilag- 
inous disk,  it  may  be  rotated  about  its  dorsovolar  axis  with  apparent 

Fig.  194. 


Fracture-lines  in  Colles'  fracture  (diagrammatic).     (Kahleyss-Oberst.) 

displacement  toward  the  ulna;  more  properly,  it  is  torn  off  with  the 
ulna.  Actual  rotation  toward  the  ulna  is  exceptional.  (Hoft'a.)  Frac- 
tures in  which  the  fracture-line  penetrates  in  the  same  direction  but 
obliquely  into  the  joint  are  rare.    The  author  has  seen  only  2  such  with 


PLATE   VI. 


Recent  Comminuted  Colles'  Fracture,  with  Longitudinal  Fracture 

Involving  the  Joint,  and  Marked  Abduction. 

After  Reduction.      (Solley.) 


FRACTURES  OF  THE  LOWER  END  OF  THE  RADIUS.        291 

the  .r-ray.  This  variety  was  first  described  by  J.  Rhea  Barton.  Lenoir 
was  forced  to  admit  that  a  case  diagnosed  as  backward  dislocation  of 
the  hand  was  such  a  fracture,  in  which  the  entire  wrist  followed  the 
backwardly  displaced  fragment. 

In  incomplete  fracture,  namely,  infraction,  the  fragment  is  still 
attached  to  the  shaft  by  its  anterior  portion  and  is  rotated  about  the 
transverse  diameter  of  the  shaft  at  the  point  of  fracture,  so  that  its 
lower  end  tilts  backward.  If  the  lower  fragment  is  comminuted — as  is 
often  seen  in  old  age,  rarely  in  childhood  or  middle  age — the  transverse 
fracture  is  combined  with  a  longitudinal  fracture  entering  the  joint. 
(Plate  VI.)  The  author  has  only  been  able  to  find  this  injury  pronounced 
in  2  patients  by  means  of  the  x-ray;  one  was  a  woman,  aged  twenty- 
eight  years,  who  had  fallen  upon  the  extended  hand,  the  other  a  man, 
aged  thirty-two  years,  the  hand  having  been  flexed.  In  older  individuals, 
as  mentioned,  it  is  more  frequent.  The  transverse  fracture-line  is  often 
somewhat  angular,  the  angle  pointing  downward,  a  sort  of  Y-fracture; 
the  outer  portion  is  usually  larger  than  the  inner.  These  comminuted 
fractures  are  often  impacted;  the  anterior  edge  of  the  upper  fragment 
usually  in  the  lower.  Voillemier  reports  such  an  impaction,  the  lower 
fragment  being  broken  into  four  pieces. 

The  "palpable"  fissures  of  the  radius  described  by  older  authors  are 
shown  by  the  .r-ray  to  be  usually  fractures  without  displacement.  In 
48  recent  fractures  of  the  radius  Kahleyss  saw  only  two  such,  both  from 
a  fall  upon  the  dorsum  of  the  flexed  hand.  In  a  series  of  50  x-ray 
pictures  of  fractures  of  the  radius  the  author  has  never  seen  a  pure 
fissure.  In  the  mildest  form  the  fine  cleft  penetrates,  according  to  v. 
Brims,  only  through  the  joint-cartilage  to  the  spongiosa.  In  the  more 
extensive  form  it  reaches  obliquely  or  axially  deeper  into  the  epiphysis, 
or  more  or  less  into  the  shaft.  Hamilton  reports  a  star-shaped  fissure. 
The  clinical  significance  of  fissures  is  in  the  involvement  of  the  radio- 
carpal joint.     Fissures  are  usually  seen  combined  with  fracture. 

The  most  frequent  injury  accompanying  fracture  of  the  radius  is  frac- 
ture of  the  styloid  process  of  the  ulna;  that  of  the  ulna  itself  is  less  com- 
mon. In  104  fractures  of  the  radius,  C.  Beck  found  fracture  or  fissure 
of  the  head  of  the  ulna  in  25  instances,  of  which  31  per  cent,  were  frac- 
ture of  the  styloid  process.  In  contrast  to  the  preceding,  Kahleyss 
and  Oberst  place  fracture  of  the  styloid  process  of  the  ulna  at  78  per 
cent.  The  author's  observations  correspond  more  to  those  of  Beck. 
The  fragment  varies  in  size  up  to  that  of  a  bean. 

Simultaneous  contusion  of  the  carpal  joints  is  of  great  prognostic 
importance.  Injury  of  individual  bones  of  the  wrist  with  fracture  of 
the  radius  was  formerly  seldom  diagnosticated,  and  was  based  chiefly 
on  supposition.  Bardenheuer  believes  that  there  is  often  simultaneous 
fracture  of  the  scaphoid;  Gocht  and  Kahleyss  have  seen  it  twice.  The 
author  has  also  seen  2  cases.  Simultaneous  fracture  of  the  os  magnum 
has  been  seen  by  Bardenheuer  in  3  instances;  by  the  author  once. 
Destoit  and  Gallois  report  the  same  of  the  unciform;  Kahleyss  once 
saw  fissure  of  the  scaphoid  and  once  fracture  of  the  same.     Authentic 


292 


INJURIES  OF  THE  WRIST  AND  HAND. 


instances  of  accompanying  dislocation  only  concern  the  scaphoid, 
according  to  the  author's  review  of  the  literature.  Important  are,  finally, 
the  comminution  of  the  cartilaginous  disk,  avulsion  of  the  same,  and 
contusions  and  fissures  of  the  cartilage  in  the  radioulnar  joint.  They 
may  cause  subsequent  pain,  functional  loss,  and  joint-deformity. 

Symptoms. — The  patients  often  come  to  the  surgeon  immediately  after 
injury,  supporting  the  arm  in  every  change  of  position  after  they  have 


Fig.  195. 


^gl^^H 


Backward  displacement  (silver-fork  deformity)  in  Colles'  fracture. 

learned  that  movement  and  jarring  produce  pain.  The  point  of  greatest 
pain  is  often  sharply  localized.  Pain  may  be  slight  with  impaction, 
increased  if  the  joint  is  involved.  A  localized  point  of  tenderness  on 
pressure  is  always  present,  and  is  often  the  most  important  symptom  if 
there  is  merely  inflexion  or  impaction;  the  characteristic  spot  is  f  to  1 
inch  above  the  styloid  process.  In  active  movements  flexion  and  exten- 
sion are  greatly  limited,  pronation  and  supination  usually  lost.     Even 

Fig.  196. 


Silver-fork  deformity  of  Colles'  fracture. 


the  elbow-joint  is  moved  reluctantly  by  the  patient,  especially  by  children. 
The  power  of  the  hand  is  greatly  diminished;  the  comfortable  position 
for  the  fingers  is  three-fourths  extended.  The  above  symptoms  are  the 
rule;  still  with  impaction,  pronation  and  supination  can  sometimes  be 
carried  out  slowly — never  to  the  normal  extent — and  apparently  without 
pain,  particularly  by  elderly  women,  in  whom  this  injury  is  most  fre- 
quent. 


FRACTURES  OF  THE  LOWER  END  OF  THE  RADIUS.        293 

Diagnosis. — The  diagnosis  is  often  made  by  inspection.  The  deformity 
is  usually  more  or  less  typical,  although  it  may  vary  greatly.  In  doubtful 
eases  compare  with  the  sound  arm  and  inspect  the  arm  on  all  sides. 
The  most  striking  change  at  first  glance  is  the  broadening  at  the  wrist; 
where  the  displacement  is  pronounced — it  is  even  recognized  by  the 
laity — the  lower  fragment  projects  backward,  and  the  cud  of  the  shaft 
presses  against  the  flexors.  (Fig.  195.)  In  consequence  of  the  retraction 
of  the  lower  fragment  and  the  shortening  of  the  radial  axis  the  hand  is 
abducted.  (Fig.  197.)  On  the  posterior  surface  above  the  joint  a  promi- 
nence is  seen  corresponding  to  one  on  the  anterior  surface  less  pro- 
nounced and  farther  from  the  wrist.  This  prominence  gives  a 
characteristic  outline  to  the  extremity,  the  silver-fork  deformity. 
(Fig.  196.)  Lateral  displacement  of  the  hand,  namely,  abduction  and 
projection  of  the  ulna  on  the  other  side,  produces  a  typical  deformity, 
termed  bayonet-deformity.  (Fig.  197.)  The  backward  displacement  of 
the  fragment  which  articulates  with  the  carpus  supinates  the  hand,  the 
shaft  of  the  radius  being  pronated. 


Fig.  197. 


S> 


^ 


Marked  abduction  (bayonet  deformity). 

On  palpating  the  posterior  surface,  if  necessary  by  displacing  the 
blood-clot  carefully,  the  edges  of  the  displaced  distal  fragment  can  be  felt. 
The  index  finger  passing  over  the  lower  end  of  the  radius  upward  toward 
the  shaft  sinks  into  a  depression  immediately  above  the  fracture,  namely, 
above  the  upper  edge  of  the  lower  fragment.  On  the  anterior  surface, 
although  the  tendons  may  make  palpation  difficult,  the  edge  of  the  frac- 
ture can  be  felt  by  passing  the  finger  along  the  radius  from  above  down- 
ward. Mobility  of  the  lower  fragment  is  recognizable  in  only  a  small 
percentage  of  the  cases,  and  in  like  manner  crepitation  is  not  obtained 
without  further  manipulation.  The  projection  of  the  lower  end  of  the 
ulna  on  the  ulnar  side  can  frequently  be  seen  and  felt,  and  the  patho- 
logical displacement  verified  by  comparison  with  the  sound  arm.  If  the 
styloid  process  of  the  ulna  is  broken  off,  pain  on  pressure  is  also  obtained 
here.  In  the  majority  of  cases  the  changes  are  not  so  conspicuous  or 
easily  felt.  Radial  deviation  of  the  hand  is  then  recognizable  only  by 
careful  comparison  and  inspection  of  the  posterior  surface  from  above. 
It  should  be  mentioned  that,  on  inspecting  from  the  radial  side,  a 
symptom  is  usually  evident,  the  importance  of  which  has  been  empha- 
sized by  Konig:  normally  from  this  point  of  view  the  radius,  especially 
if  pronated,  shows  a  slight  curve  convex  toward  the  posterior  surface. 
In  fracture  this  bowing  is  absent,  even  if  the  displacement  is  slight,  or 


294  INJURIES  OF  THE  WRIST  AND  HAND. 

the  curve  is  in  the  opposite  direction.  (Fig.  195.)  Recognition  and 
due  appreciation  of  this  sign  never  leave  one  in  doubt  and  are  of  great 
diagnostic  value  even  in  the  slight  displacement  of  typical  fracture. 

As  the  larger  number  of  cases  are  impacted  fractures  (Diday,  Callen- 
der,  all  recent  authors),  it  would  be  a  mistake  to  attempt  to  elicit  crepitus 
by  force.  By  palpation,  as  mentioned,  crepitus  is  not  usually  obtainable. 
In  determining  the  value  of  the  localized  pressure-pain  it  is  a  good 
rule  to  approach  it  from  the  adjacent  parts  of  the  radius.  If  localized 
h  to  1  inch  above  the  end  of  the  radius,  it  is  pathognomonic.  It  is 
obtained  better  by  proceeding  slowly,  pressing  with  the  end  of  the  index 
finger,  than  by  grasping  indiscriminately  with  the  entire  hand.  [An  even 
more  delicate  test  is  to  use  the  edge  of  a  rule,  end  of  a  lead-pencil,  etc.] 

If  the  examiner  merely  obtains  pain  on  pressure,  and  the  same  is 
pronounced  at  the  foveola  radialis  (tabatiere  anatomique)  he  will  sel- 
dom err  in  assuming  an  isolated  fracture  of  the  styloid  process  of  the 
radius.  The  author  has  seen  this  injury  rather  frequently.  He  does  not 
resort  to  the  x-ray  for  volar  dislocation  of  a  single  bone  of  the  wrist  not 
associated  with  fracture  of  the  tip  of  the  styloid  process,  but  assumes  the 
existence  of  this  isolated  dislocation  from  the  preponderance  of  the  tear- 
ing force,  which  by  maximal  hyperextension  may  so  act  that  the  wrist  slips 
under  on  the  anterior  surface  instead  of  pressing  forciblyagainst  the  radius. 
Comminution  and  fissures  can  be  presumed  rather  than  palpated  with 
certainty,  in  which  case  the  diagnosis  will  depend  upon  the  x-ray.  The 
same  applies  to  the  simultaneous  involvement  of  individual  bones  of  the 
wrist.  A  fracture  or  dislocation  of  one  of  these  bones  may  be  presumed 
from  pain  on  pressure  or  abnormal  prominence,  exceptionally  from 
crepitus;  still,  a  definite  conclusion  as  to  the  details  will  hardly  be  possible 
without  the  x-ray. 

Injuries  of  the  disk  (Nelaton)  are  recognizable  by  passive  supination 
and  pronation,  if  not  by  direct  palpation  (crepitus);  also  by  false  motion 
and  projection  of  a  movable  fragment  of  cartilage.  That  this  cartilage  is 
frequently  involved  is  explained  by  the  mechanism  of  the  injury.  The 
extent  of  involvement  is  not  always  easily  determined;  occasionally  at 
the  site  of  the  cartilage  there  may  be  merely  pain  on  pressure  lasting 
for  some  time;  or  slight  crepitus;  or  the  signs  of  beginning  arthritis 
deformans.    These  symptoms  make  injury  of  the  disk  probable. 

The  radio-ulnar  joint  closed  off  by  the  disk  may  be  severely  injured 
without  evident  lesion  of  the  latter.  The  injury,  if  recent,  may  be 
manifested  merely  by  effusion;  later,  pronation  and  supination,  flexion, 
and  extension  may  be  impaired  for  a  long  time  by  reason  of  the  pain 
produced  and  the  existence  of  deforming  processes.  In  like  manner 
the  radiocarpal  joint  is  often  severely  contused  without  apparent  fracture 
of  any  of  the  carpal  bones.  Long-standing  effusion  followed  by 
connective-tissue  growths  in  the  synovial  membrane,  thickening  and 
shrinkage  of  the  latter,  and  secondary  impairment  of  motion,  are  the 
accompanying  and  resulting  symptoms. 

A  rare  associated  injury,  to  which  the  author  has  never  found  reference 
made,  and  the  presence  of  which  he  has  often  regarded  as  probable  on 


PLATE   VII 


Recent  Colles'  Fracture   in  a  Boy  Twelve  Years  Old,  showing 
Epiphyses.      (Stimson.) 


FIG.    2. 


Old  Fracture  of  Radius  and  Ulna,  with   Reversal,  Overriding, 
and  Weak   Callus.      (Solley. ) 


FRACTURES  OF  THE  LOWER  END  OF  THE  RADIUS.        295 

account  of  the  great  sensitiveness  of  the  base  of  the  second  metacarpal 
and  the  impaired  pronation  of  the  hand,  is  the  overstretching,  tearing, 
or  avulsion  from  its  insertion  of  the  tendon  of  the  extensor  carpi  radialis. 

In  the  differential  diagnosis  the  rare  backward  dislocation  of  the  wrist 
is  to  he  considered;  for  it  and  against  fracture  are  the  complete  con- 
tinuity of  the  radius  to  the  tip  of  the  styloid  process;  the  absence  of 
sensitiveness  along  the  bone;  lack  of  crepitus  and  of  radial  adduction 
of  the  hand;  the  prominence  of  the  curved  articular  surface  of  the  upper 
row  of  carpal  bones  and  the  flexed  position  of  the  hand.  The  diagnosis 
between  infraction,  impaction  with  slight  shortening  and  contusion  is 
sometimes  more  difficult.  Careful  palpation  of  the  continuity,  examina- 
tion for  points  of  tenderness,  and  for  slight  widening  and  inflexion  of 
the  lower  end  of  the  radius;  in  short,  the  critical  analysis  of  the  above 
diagnostic  signs,  will  hardly  allow  the  conscientious  examiner  to  make 
a  wrong  diagnosis. 

Treatment. — The  first  principle  of  treatment  is  to  reduce  all  recog- 
nizable displacements.  If  the  backward  displacement  of  the  lower  frag- 
ment is  pronounced,  the  middle  of  the  forearm  of  the  patient  is  grasped 
with  the  left  hand  and  the  thumb  or  index  finger  used  to  control  the  frag- 
ments. The  hand  is  grasped  at  the  metacarpus  with  the  right  hand  and 
quick  and  increasing  traction  is  exerted  in  the  axis  of  the  forearm.  With 
this  grip  many  displacements  can  be  reduced  completely ;  doubtless  it  will 
often  require  simultaneous  traction  in  the  sense  of  forced  flexion  and  pro- 
nation, for,  as  has  been  seen,  the  lower  fragment  is  pushed  back  in  supina- 
tion at  the  time  of  injury,  while  the  rest  of  the  radius  is  forcibly  pronated. 
The  author  approves  of  combining  flexion  and  pronation,  as  the  hand 
is  thus  brought  into  the  best  position  for  maintaining  the  reduction  in 
the  splint.  The  desired  effect  is  obtained  maximally  by  pronating  and 
finally  adductiug  the  hand.     (Cline,  Dupuytren.) 

If  reduction  fails  in  this  way,  forcible  extension  (dorsal  flexion),  as  em- 
ployed by  Roser  and  recently  recommended  by  Konig,  followed  again  by 
traction,  as  mentioned  above,  may  succeed.  For  fracture  caused  by  a  fall 
upon  the  dorsum  of  the  flexed  hand,  the  manipulation  will  be  in  the 
opposite  direction.  If  in  impacted  fractures  there  is  displacement  and 
marked  radial  deviation  of  the  hand,  the  author  is  careful  to  obtain 
proper  correction  by  loosening  the  fragments  and  manipulating  until  suc- 
cessful. Herein  lies  the  salient  point  of  treatment.  Non-recognition 
and  non-reduction  of  the  displacement  may  be  accompanied,  under 
circumstances,  by  very  serious  results. 

The  author  often  uses  anaesthesia.  If  assistance  is  employed,  the 
operator  has  both  hands  for  traction  and  manipulation,  the  assistant 
exerting  countertraction  upon  the  elbow  and  upper  arm.  Extension  is 
facilitated  over  a  fulcrum,  namely,  over  the  knee  or  a  sand-bag,  book, 
block  of  wood,  or  the  edge  of  a  table.  The  extent  of  manipulation  and 
the  entire  teehnic  employed  depend  upon  the  amount  of  displacement 
present.  In  pronounced  oblique  fracture  as  well  as  in  transverse  fracture, 
there  is  a  great  tendency  for  the  displacement  to  return  if  the  surfaces 
of  upper  and  lower  fragment  are  not  entirely  apposed.    After  reduction 


296  INJURIES  OF  THE  WRIST  AND  HAND. 

the  line  of  continuity  of  the  radius  should  be  unbroken.  Isolated 
fracture  of  the  tip  of  the  styloid  process  does  not  require  reduction,  just 
as  fracture  of  the  same  process  of  the  ulna  does  not  need  special 
measures.  If  the  ulna  is  displaced  outward  to  any  extent  after  rupture 
of  the  cartilaginous  disk,  the  correction  of  the  deformity  is  often  incom- 
plete. Dislocation  of  single  carpal  bones  will  be  overcome  if  possible 
(often  without  the  desired  result)  in  case  of  forward  dislocation  by 
extreme  extension. 

The  author  established  above  why  the  reduction  is  best  maintained 
by  supinating  the  shaft  of  the  radius  and  flexing  and  adducting  the  hand. 
For  this  reason  this  position  should  be  sought  as  the  ideal  one.  The 
author  is  guided  personally  by  the  experience  that  a  properly  applied 
plaster-strip  splint  insures  this  position  most  accurately,  and  is  therefore 
to  be  recommended  where  there  is  a  tendency  to  displacement. 

One  or  two  plaster  roll  bandages  are  soaked  and  laid  out  upon  a  flat 
surface  by  folding  back  and  forth,  the  length  of  the  strip  corresponding 
to  the  distance  from  the  heads  of  the  metacarpals  to  the  middle  of  the 
upper  arm.  The  layers  are  built  up  to  the  proper  thickness  by  using 
one  or  two  rolls,  smoothing  down  each  successive  layer.  A  piece  of 
flannel  is  then  cut  about  §  inch  larger  on  all  sides  than  the  plaster  strip; 
the  strip  is  then  laid  upon  it,  and  with  the  flannel  side  toward  the  skin 
it  is  applied  to  the  flexor  surface — rarely  extensor  surface — of  the  fore- 
arm, reaching  from  the  middle  of  the  upper  arm  to  the  heads  of  the 
metacarpals;  it  is  then  bandaged  with  muslin  or  flannel  roll  bandages, 
the  arm  being  held  by  an  assistant.  If  necessary,  the  arm  can  be 
manipulated  after  the  splint  is  applied,  to  obtain  the  proper  position. 

If  the  tendency  to  displacement  is  slight,  the  splint  may  stop  at  the 
elbow;  but  where  it  is  desired  to  immobilize  the  entire  radius  the  elbow- 
joint  should  be  included.  The  splint  is  thus  adaptable  to  the  individual 
case,  leaves  one  side  of  the  arm  free  for  inspection  and  for  the  circulation, 
and  is  comfortable.  The  renewal  of  the  splint  depends  upon  circum- 
stances. The  author  often  leaves  it  in  position  from  two  to  two  and  a 
half  weeks  until  consolidation  has  advanced  to  the  point  where  absolute 
fixation  is  no  longer  necessary.  Massage  about  the  fracture  and  joint 
on  the  free  surface  can  begin  on  the  sixth  to  eighth  day.  As  especially 
emphasized  by  Schede,  it  is  very  important  to  leave  the  fingers  out, 
particularly  in  elderly  individuals.  Quite  properly  the  circular  plaster 
splint  is  no  longer  used  by  most  surgeons  for  recent  injuries.  If  it  is 
not  well  padded,  the  bad  results — ischemic  paralysis,  persistent  joint 
disturbances,  etc. — -are  not  excluded;  if  it  is  well  padded,  it  does  not 
meet  the  indication  for  which  it  is  applied.  There  is  no  objection  to 
its  application  after  the  blood  extra vasate  has  subsided. 

Of  the  numerous  other  methods  of  using  strips,  only  those  will  be 
mentioned  that  have  been  well  tested.  The  practice  and  custom  of  the 
individual  will  determine  the  choice  of  this  or  that  method.  With  the 
proper  selection  there  are  many  roads  to  success,  for  the  time  has  passed 
when  every  new  observation  of  fracture  of  the  radius  would  lead  to  a 
new  splint.    The  picture  of  the  injury  stands  finished  before  the  surgeon ; 


FRACTURES  OF  THE  LOW  Ell  END  OF  THE  RADIUS. 


297 


the  simpler  the  appropriate  method  is,  the  greater  its  claim  for  recog- 
nition. 

( )n  the  grounds  of  a  wide  experience,  Konig  recommends  Roser's 
posterior  splint  with  a  pad  on  the  hack  of  the  hand.  (Fig.  198.)  "A 
splint  about  the  width  of  the  arm  begins  at  the  external  condyle  and 
extends  at  least  to  the  first  phalanges  of  the  fingers.  Naturally  it  is 
well  padded.  It  is  so  applied  to  the  hack  of  the  arm  and  the  hand  that 
the  hand  is  allowed  to  hang  down  in  flexion.    The  splint  is  thus  in  contact 


Fig.  19S. 


Roser's  splint  for  Colles'  fracture. 


with  the  arm  only  to  the  wrist;  the  free  space  beyond  to  the  fingers  is 
filled  in  best  with  firm  graduated  linen  compresses,  so  applied  as  to  form 
a  wedge.  The  tapered  end  lies  directly  upon  the  lower  backwardly 
displaced  fragment.  The  fingers  are  left  free  in  order  that  they  may  be 
moved  while  the  splint  is  in  place.  The  entire  arm  down  to  the  fingers  is 
now  bandaged  with  flannel  firmly  against  the  splint.    The  dorsal  pad  thus 

Fig.  199. 


N(51aton's  pistol  strip. 


presses  against  the  projecting  lower  fragment.  The  tendency  of  the 
upper  fragment  to  become  displaced  is  prevented  by  its  being  drawn 
tightly  against  the  posterior  splint  above  the  pad.  If,  however,  the 
upper  end  still  shows  a  tendency  to  forward  displacement — which,  by 
way  of  digression,  has  never  happened  in  the  author's  experience — a 
short  anterior  splint  may  be  added,  reaching  to  the  wrist,  with  a  pad 
above  the  wrist." 

Another  posterior  splint  often  used  is  Nelaton's  pistol  strip.    (Fig.  199.) 


298 


INJURIES  OF  THE  WRIST  AND  HAND. 


The  most  adaptable,  and  for  this  reason  the  most  advisable,  splint  for 
the  practising  surgeon  is  Schede's  anterior  strip.  (Fig.  200.)  Gutter 
splints  of  metal  or  wood  are  recommended  by  Dupuytren,  Chelius, 
Blandin,  and  Goyrand;  recently  for  ulnar  application  by  Kolliker.     It 


Fig.  200. 


Schede's  anterior  strip  splint. 


Fig.  201. 


should  not  be  omitted  that  the  experienced  Roser  has  abandoned  all 

splints  that  merely  adduct  the  hand  and  wrist. 

The  treatment  of  fracture  without  splints  has  recently  found  several 

advocates.    Helferich  recommends  Storp's  suspension-cuff  (Fig.  201): 

"After  reduction  is  accomplished, 
the  hand  is  brought  into  extreme 
adduction  and  flexion  (ulnar- 
volar  flexion);  a  strip  of  adhesive 
plaster  about  4  inches  wide  is 
wound  several  times  around  the 
lower  end  of  the  forearm  down  to 
the  styloid  process;  a  second  strip 
forms  a  loop  over  it  on  the  poste- 
rior surface,  to  which  a  sling  is 
fastened.  The  author  places  the 
suspension  loop  midway  between 
the  side  and  back  of  the  radius, 
so  that  the  suspended  hand  hangs 
down  toward  the  ulnar  and  volar 
surface."  Faenger  places  the  arm 
upon  a  double-inclined  plane,  the 
flexed  wrist  lying  on  the  ridge. 
Petersen  recommends  as  the  best 
method  for  fracture  of  the  radius 

that  the  hand  be  allowed  to  hang  over  the  edge  of  a  carrying-cloth  in 

adduction  ;  this  suffices  to  hold  the  fragments  in  the  proper  position. 
Konig  and  Bardeleben  have  warned  against  the  generalization  cf  this 

method,  quite  properly  it  appears  to  the  author.     At  an  earlier  period 


Storp's  suspension-cuff.     (Helferich.) 


FRACTURES  OF  THE  LOWER  END  OF  THE  RABIES. 


299 


Velpeau  objected  urgently  against  such  experiments,  for  in  the  first  place 
this  method  presupposes  on  the  part  of  the  patient  an  amount  of  intelli- 
gence which  does  not  appertain  in  the  average  case.  In  the  event  of 
failure  the  attending  surgeon  is  nor  .-pared  reproach  for  treatment  com- 
parable to  "almost  none."  Even  the  sensitiveness  of  the  patients  can 
frequently  make  its  application  impossible. 

After-treatment  and  Prognosis. — In  general,  the  statement  is  correct 
that  typical  fracture  of  the  radius,  by  appropriate  treatment  and  in  the 
absence  of  functional  disturbance  resulting  from  callus,  recovers  in  from 
two  to  four  weeks.    In  young  subjects  this  is  almost  without  exception; 

Fig.  202. 


Plaster-of-Paris  splints  for  Colles'  fracture.     (Stimson.) 

in  men  of  the  laboring  classes,  especially  those  who  bask  in  the  light  of 
accident  legislation,  the  author  does  not  see  the  full  use  restored 
before  the  sixth  to  eighth  week.  In  old  age  the  fracture  often  requires 
special  care. 

As  mentioned,  the  author  leaves  the  first  splint  (plaster-strip  splint)  on 
from  ten  to  fourteen  days,  ordinarily  without  aiding  resorption  of  the 
extravasation  by  massage  on  the  free  surface  during  this  time.  Later  the 
patient  returns  daily  or  every  other  day  for  one  or  two  weeks  for  massage 
and  movements,  if  the  condition  of  the  fracture  warrants.    The  splint  is 


Fig.  203. 


Wooden  splints  for  Colles'  fracture.     (Stimson) 

still  worn  during  this  time  and  removed  during  the  massage,  or  is  later 
replaced  by  a  lighter  splint.  Meanwhile  the  wrist  is  flexed  and  extended 
passively,  the  arm  is  carefully  pronated  and  supinated,  and  all  the 
finger-joints  exercised  passively.  During  this  time  massage  is  essen- 
tial for  early  return  of  function  if  there  is  extravasation  in  the  wrist  or 
about  the  fracture.  If  on  first  removing  the  splint  displacement  still 
exists,  reduction  by  manipulation  is  unconditional. 

Frequently  simultaneous  contusion  of  the  carpal  joints  and  injuries 
of  the  radio-ulnar  joint,  sometimes  combined  with  injury  of  the  car- 


300  INJURIES  OF  THE  WRIST  AND  HAND. 

tilaginous  disk,  give  trouble  for  a  longer  time  than  the  fracture  itself. 
More  or  less  severe  deforming  processes  in  the  joints  involved  are  not 
rare  up  to  the  fiftieth  year  in  spite  of  careful  after-treatment;  particularly 
adhesions  of  the  flexor  tendons  caused  by  cicatricial  contraction  of  the 
sheaths  after  long-standing  effusion,  adhesions  due  to  growth  of 
callus,  and  the  secondary  motor  disturbances  of  the  fingers,  demand 
constant  attention.  All  measures,  such  as  protracted  water-  or  sand- 
baths,  used  in  connection  with  massage,  and  the  movements  aiding 
circulation  and  resorption,  are  meanwhile  to  be  employed  if  warranted 
by  the  subjective  condition  of  the  patient.  Nevertheless  the  author 
sometimes  sees  long-continued  impairment  of  motion  followed  by  atrophy 
of  the  muscles  concerned,  particularly  in  elderly  women,  and  especially 
if  sensitiveness  demands  absolute  immobilization  for  a  greater  length  of 
time  or  if  motion  or  massage  is  refused  by  the  patient.  Up  to  the  sixth 
month  secondary  reduction  may  be  indicated  by  deforming  callus  or 
union  with  displacement;  after  this,  osteotomy,  either  of  the  radius  alone 
or  also  of  the  ulna,  is  to  be  considered.  For  synostosis  forming  between 
the  radius  and  ulna,  resection  of  the  capitulum  of  the  ulna  is  proposed 
by  Lesser  and  has  been  done  successfully  by  him  and  by  Lauenstein. 
Pseudarthrosis  is  rare. 


FRACTURE  OF  THE  CARPAL  BONES. 

The  bones  of  the  carpus  are  so  fused  together  by  the  posterior, 
anterior,  and  intercarpal  ligaments  that  it  is  often  difficult  to  determine 
by  palpation  where  the  fracture  lies.  All  fractures  of  the  carpus  presup- 
pose marked  direct  or  indirect  violence,  so  that  we  usually  find  likewise 
severe  injuries  of  the  soft  parts.  The  latter  easily  conceal  the  signs 
of  fracture  and  previous  to  using  the  .r-ray  one  often  has  to  be  satisfied 
with  a  probable  diagnosis  of  fracture.  Pain,  usually  intense,  severe 
functional  disturbance,  and  marked  extravasation  of  blood  support  the 
diagnosis. 

Bony  ankylosis,  recognized  subsequently  in  the  absence  of  fracture 
of  the  radius,  is  almost  always  the  result  of  fracture  of  part  of  the  carpus. 
The  fracture  involves  commonly  only  a  part  of,  very  rarely  the  entire, 
carpus.  The  author  has  repeatedly  seen  simultaneous  fracture  of  the 
os  magnum,  unciform,  and  lunar  produced  by  a  blow.  Indeed,  he 
regards  these  bones  as  the  ones  predisposed  to  fracture,  considering  the 
nature  of  the  forces  usually  concerned.  Occasionally  the  scaphoid  is 
also  involved;  more  commonly  it  is  fractured  by  the  force  producing 
fracture  of  the  radius,  or  it  accompanies  the  latter. 

The  diagnosis  of  isolated  fracture  of  single  carpal  bones  presents 
about  the  same  difficulty,  although  local  crepitus  may  be  of  assist- 
ance. The  injury  is  apt  to  be  accompanied  by  severe  laceration  of 
the  soft  parts,  especially  the  ligaments,  and  then  has  an  unfavorable 
prognosis.  Heavy  manual  labor  is  often  impossible  for  a  long  time. 
The  scaphoid  and  pisiform  are  the  most  frequent  examples  of  isolated 


> 

< 

CL 


< 


DISLOCATION  OF  THE  WHIST.  301 

fracture.  The  pisiform  is  broken  by  a  fall  upon  the  extended  hand; 
occasionally  there  is  simultaneous  laceration  or  avulsion  of  the  flexor 
carpi  ulnaris  and  corresponding  functional  loss.  Fracture  of  the  scaphoid 
results  indirectly  from  a  fall  upon  the  outstretched  hand  while  strongly 
extended,  abducted,  ami  pn  oated  forcibly.  (Plate  VIII.)  The  steps  of 
the  injury  are  usually  described  as  similar  to  those  of  fracture  of  the 
radius.  There  may  he  distinct  localized  crepitus  below  the  radius. 
In  an  analogous  manner  the  cuneiform  is  broken  if  the  hand  is  ad- 
ducted  at  the  moment  of  injury.  Direct  violence,  particularly  a  shot- 
wound,  may  affect  all  the  carpal  bones,  in  which  case  the  diagnostic 
evidence  is  so  pronounced  that  it  can  be  scarcely  overlooked. 

Treatment. — The  first  object  of  treatment  is  to  alleviate  the  severe 
pain.  The  author  has  repeatedly  aspirated  large  hemorrhages  in  the 
joint.  Actual  comfort  is  obtained  by  absolute  immobilization  upon  a 
straight  splint  and  by  use  of  the  ice-bag,  and  is  increased  by  elevating  the 
hand.  At  the  end  of  several  days,  massage,  and  later  passive  motion, 
should  be  begun.  Ankylosis  sometimes  occurs,  and  its  later  removal 
causes  renewed  severe  pain.  At  about  the  second  week  compression  and 
warm  baths  are  well  borne  and  hasten  recovery.  Early  active  use,  as 
soon  as  the  pain  allows,  is  desirable  and  should  be  gradually  increased. 


DISLOCATION  OF  THE  WKIST. 

Dislocation  of  the  wrist,  at  an  earlier  period  frequently  included  in 
and  confused  with  the  diagnosis  of  fracture  of  the  radius,  is  supposed 
to  have  been  relegated  to  the  realm  of  pure  phantasy  by  Dupuvtren's 
extreme  point  of  view.  This  is  opposed  to  the  facts,  as  dislocation  of 
the  wrist  is  a  positive  although  extremely  rare  observation. 

Dislocation  of  the  entire  carpus  upon  the  forearm,  backward  as  well 
as  forward,  has  been  seen.  It  is  sometimes  complicated  by  fracture  of 
the  styloid  process  of  the  ulna.  Fracture  of  part  of  the  joint-surface  of 
the  radius  has  also  been  seen  with  it.  (Parker.)  YViessner  reports  a 
bilateral  injury  in  a  boy  fourteen  years  old  who  had  fallen  from  a  height. 
The  difficulty  in  the  production  of  the  injury  is  due  to  the  strength  of 
the  posterior  and  especially  to  the  even  stronger  anterior  ligaments. 
Violence,  chiefly  direct,  acting  upon  the  dorsum  may  cause  the  for- 
ward dislocation.  The  more  frequent  dislocation  backward  upon  the 
bones  of  the  forearm  may  result  from  a  fall  upon  the  back  of  the 
hand  while  it  is  hyperflexed.  In  both  cases  the  relation  of  the  styloid 
processes  to  the  carpus  is  decisive  for  the  diagnosis:  in  dislocation  without 
simultaneous  fracture  they  must  lie  in  the  prolonged  axis  of  the  radius 
and  ulna.  (Fig.  204.)  In  backward  dislocation  the  proximal  part  of 
the  carpus  lies  upon  the  lower  ends  of  the  bones  of  the  forearm  and 
lifts  up  the  extensor  tendons.  On  the  flexor  surface  the  ulna  and  radius 
project  correspondingly,  the  styloid  processes  being  easily  felt.  They 
can  protrude  between  the  flexors  and  the  adductor  pollicis  longus  and 
perforate  outward  through  the  fascia  and  skin.    Occasionally  the  articu- 


302  INJURIES  OF  THE  WRIST  AND  HAND. 

lar  surface  of  the  radius  can  be  felt  on  the  flexor  surface.  The  promi- 
nence on  the  posterior  surface  is  much  more  abrupt  than  in  fracture  of 
the  radius;  it  includes  the  entire  width  of  the  back  of  the  hand  and  its 
curved  border,  convex  upward,  can  be  felt  plainly  by  careful  palpation. 
The  axis  of  the  hand  usually  shows  no  deviation  from  that  of  the  fore- 
arm; the  hand  is  flexed  slightly — in  forward  dislocation  it  is  extended 
slightly— and  the  fingers  are  semiflexed  at  the  metacarpophalangeal 
joints. 

There  is  no  difference  in  the  length  of  the  hand  compared  with  the 
sound  one,  or  in  the  length  of  the  radius  or  of  the  ulna  from  the  olecranon 
to  the  styloid  processes;  still,  the  distance  from  the  olecranon  to  the  tip 
of  the  middle  finger  is  evidently  shorter  compared  with  the  sound  side. 
This  shortening  can  only  be  explained  by  displacement  at  the  wrist- 
joint.    The  avray  will  remove  all  doubts  as  to  the  condition. 

Fig.  204. 


Backward  dislocation  of  the  carpus. 

Treatment. — Reduction  is  usually  effected  quickly  by  traction  and 
flexion  in  the  same  direction  in  which  the  injury  was  produced.  The 
functional  prognosis  is  doubtful,  however,  on  account  of  the  injury  of 
the  soft  parts.  There  is  also  a  tendency  to  recurrence.  It  is  a  good 
plan  to  immobilize  the  hand  for  a  short  time — in  backward  dislocation 
slightly  extended,  in  forward  dislocation  flexed — in  order  to  approxi- 
mate the  torn  ligaments  as  much  as  possible;  further,  to  maintain  the 
carpus  in  position  by  the  moderate  pressure  of  a  pad.  Resection  will 
be  necessary  only  exceptionally  where  reduction  is  impossible  on  account 
of  the  hindrance  caused  by  portions  of  the  carpus  or  where  the  injury 
is  of  longer  standing. 

Habitual  and  voluntary  dislocation  of  the  carpus  upon  the  forearm 
has  been  seen.  Little  is  known  of  post-traumatic  habitual  dislocation 
on  account  of  its  rarity;  still  we  find  statements  of  "recurrence"  of  the 
dislocation  during  the  first  weeks  after  the  injury.  A  case  of  voluntary 
forward  subluxation  came  under  the  author's  observation.  The  patient 
concerned,  a  young  surgeon,  had  the  full  use  of  his  left  hand,  but  was 
able  at  will,  without  the  assistance  of  the  other  hand,  to  produce  the 
dislocation  with  a  snap.  The  prominence  of  the  extensors  caused  by 
the  forward  displacement  of  the  carpus  was  very  characteristic.  He 
was  also  able  to  dislocate  the  left  thumb  and  both  tibias  at  the  knee. 
The  dislocations  never  occurred  involuntarily.  Madelung  has  described 
in  detail  a  subluxation  of  the  wrist  seen  at  times  in  young  seamstresses. 


DISLOCATION  OF  THE  WRIST.  303 

If  the  capsule  is  relaxed,  severe  handwork  soon  produces  a  forward  dislo- 
cation of  the  wrist;  the  ulna  and  radius  are  displaced  backward.  During 
the  development  of  the  lesion  extension  of  the  hand  is  very  painful. 
Although  reduction  is  impossible,  strengthening  the  muscles  and  the 
proper  kind  of  work  improve  the  condition. 

Intercarpal  dislocation  of  the  second  row  upon  the  first  (luxatio 
medio-carpienne  of  Malgaigne  and  Depres),  both  forward  (Malgaigne, 
Bardenheuer)  and  backward  (Maisonneuve),  have  been  reported.. 
Mechanical  force  or  a  fall  from  a  height  are  given  as  the  causes.  Till- 
manns  reports  an  incomplete  anterior  intercarpal  dislocation;  it  was 
produced  by  the  muscular  force  exerted  in  lifting  a  jar.  The  diagnosis 
was  made,  in  this  case  as  in  one  reported  by  Bahr,  with  the  x-ray. 

Dislocation  of  the  Ulna  or  Radius  Alone. — Isolated  dislocation  of 
the  ulna,  either  backward  or  forward,  is  a  very  rare  injury  in  spite  of 
the  frequency  of  dislocation  with  marked  prominence  of  the  styloid 
process  in  fracture  of  the  radius.  Backward  dislocation  is  supposed  to 
be  produced  by  forced  pronation,  the  forward  variety  by  forced  supina- 
tion. In  both  instances  the  transverse  diameter  of  the  lower  end  of  the 
forearm  is  shortened.  The  diagnosis  is  simple.  The  author  has  seen 
only  one  instance,  and  that  was  an  old  unreduced  dislocation;  the  mode 
of  origin  could  not  be  accurately  ascertained.  In  like  manner  the  author 
has  seen  only  one  instance  of  isolated  habitual  dislocation  of  the  ulna 
which  was  not  questionable.  The  function  of  the  hand  was  compromised 
so  little  that  operative  treatment  was  refused  by  the  patient,  a  man  of 
forty  years.  For  this  condition  Hoffa  opened  the  joint  by  two  lateral 
incisions  and  sutured  the  periosteum  with  apparent  success  in  3  instances. 
The  statement  of  Goyrand,  that  this  dislocation  is  frequent  in  childhood, 
cannot  be  corroborated  in  spite  of  the  relatively  large  material  at  our 
disposal.  The  author  sides  rather  with  Konig's  statement  that  the  pain 
in  the  wrist  sometimes  caused  by  traction  upon  the  hand  is  quickly 
relieved  by  extending  and  supinating.  All  the  injuries  reported  as 
isolated  dislocations  of  the  lower  end  of  the  radius  resolve  themselves 
on  critical  examination  into  fractures  of  the  radius. 

Dislocation  of  Single  Bones  of  the  Wrist. — Dislocation  of  single 
bones  of  the  wrist  lays  claim  to  greater  practical  importance  than  is 
apparently  attributed  to  it  in  the  earlier  compilations  of  Tillmanns  and 
Bardenheuer.  The  x-ray  has  rapidly  increased  the  figures,  and  in  all 
cities  where  many  injuries  of  the  extremities  are  determined  by  the  .r-rav 
these  findings  are  reported.  The  importance  of  the  lesion  lies  in  the 
fact  that  the  resulting  functional  loss  is  apt  to  be  pronounced;  the 
reduction  may  be  very  difficult,  possibly  not  attempted  on  account  of 
a  wrong  diagnosis  and  under  circumstances  may  require  resection.  On 
superficial  examination  it  is  diagnosticated  as  sprain,  contusion,  or  frac- 
ture of  the  radius,  but  can  hardly  be  overlooked  by  careful  palpation, 
especially  under  control  of  the  x-ray. 

Surgeons  are  indebted  to  Eigenbrodt  for  a  recent  elaboration  of  the 
existing  statistics  in  connection  with  his  own  observations.     From  this 


304  INJURIES  OF  THE  WRIST  AND  HAND. 

review  it  would  seem  that  the  predisposition  of  the  os  magnum,  as  em- 
phasized on  various  sides,  does  not  correspond  with  the  facts.  Complete 
isolated  dislocation  of  this  bone  has  not  been  reported  up  to  the  present 
time.  On  the  other  hand,  spontaneous  subluxation  of  the  head  of  the  os 
magnum  alone  or  with  the  upper  part  of  the  unciform  has  occurred  back- 
ward if  the  ligaments  were  relaxed  (according  to  Bardenheuer,in  weavers; 
according  to  Roser  and  Konig,  in  women).  Eigenbrodt  states  that  iso- 
lated dislocation  of  the  trapezium  or  trapezoid  has  never  been  reported, 
or  at  best  only  inaccurately.  In  the  cases  described  as  dislocation  of  the 
pisiform  the  bone  was  fractured  by  the  traction  of  the  flexor  carpi  ulnaris. 
Likewise  in  the  few  instances  of  dislocation  of  the  unciform  there  was 
never  merely  a  dislocation,  but  always  simultaneous  injury  of  other  bones 
(metacarpals),  the  fracture  of  which  latter  permitted  the  dislocation. 
Only  scattered  and  mostly  old  reports  are  extant  of  dislocation  of  the 
scaphoid  or  portions  of  the  same.  It  is  different  with  regard  to  the 
dislocation  of  the  lunar;  it  may  claim  the  significance  of  a  typical  injury. 
By  forcible  hyperextension  of  the  hand  the  lunar  and  scaphoid  are 
pressed  against  the  metacarpals,  and  after  the  flexor  ligaments  have  been 
torn  both  bones  or  one,  usually  the  lunar,  are  forced  out  by  the  pressure 
of  the  os  magnum.  The  pressure  of  the  dislocated  bone  sometimes 
causes  paralysis  of  the  median  or  ulnar  nerve. 

Treatment. — For  all  the  above  dislocations  reduction  should  be 
attempted  by  maximal  extension  for  the  forward  variety,  extreme  flexion 
for  the  backward  variety,  followed  by  pressure  upon  the  bone  and 
gradual  return  of  the  wrist  to  its  normal  position.  Operation  is  resorted 
to  more  frequently  at  the  present  time  than  formerly  if  reduction  is 
impossible,  and,  if  necessary,  the  resection  of  single  bones.  Often  the 
injury  was  only  one  of  many  produced  by  falling  from  a  height,  and  the 
patients  died  before  any  plan  of  treatment  could  be  considered.  It 
should  be  mentioned  that  very  satisfactory  results  are  sometimes  obtain- 
able by  simple  immobilization  of  the  wrist  and  subsequent  exercises,  as 
in  a  case  of  Eigenbrodt's  in  which  there  was  complete  return  of  function 
in  two  and  a  half  years  without  reduction  or  operation. 


COMPLICATED  INJURIES  ABOUT  THE  WRIST. 

Complicated  injuries  of  the  wrist  are  chiefly  the  result  of  machinery 
accidents,  shot- wounds,  run-over  accidents,  penetrating  and  perforating 
wounds  from  within  similar  to  those  occurring  more  frequently  in  the 
ankle-joint.  The  hand  may  be  caught  in  belting,  be  severely  crushed, 
caught  in  combiner-  or  toothed-wheels,  or  between  rollers;  extensive 
laceration  or  avulsion  of  the  soft  parts  may  be  complicated  by  opening 
of  the  joint,  by  one  or  more  fractures  of  the  bones;  cutting  instruments 
may  sever  the  hand  partially  or  completely,  the  cut  being  clean  or 
jagged.  The  results  of  conservative  treatment  are  often  surprisingly 
successful  in  injuries  of  this  sort,  the  later  aspect  of  the  wound  giv- 
ing no  clue  to  the  injury.     If  sepsis  occurs,  there  may  be  severe  func- 


COMPLICATED  I  S.I  CRIES  MioCT  THE   WHIST.  305 

tional  loss,  ankylosis,  contractures,  and  disturbances  of  innervation  and 
circulation. 

The  hemorrhage  is  often  comparatively  slight  in  all  of  these  injuries: 
the  vessels  are  torn,  twisted,  and  closed  by  the  injury.  This  occlusion 
may  be  deceptive,  and  be  followed  by  severe  hemorrhage  if  the  parts 
are  moved,  as  in  transportation.  The  author  has  repeatedly  seen 
instances  where  portions  of  the  radial  or  ulnar  artery,  several  inches  in 
length,  were  torn  out  of  the  adjacent  tissues,  pulsating  in  their  entire 
length,  hut  closed  spontaneously  by  the  torsion.  Such  injuries  were  often 
accompanied  by  evulsion  of  the  muscles,  splinter-fractures  of  the  carpal 
and  metacarpal  hones,  or  complete  or  incomplete  dislocation  of  the 
latter.  The  vessels  are  never  difficult  to  find  at  the  wrist,  and  with 
proper  attention  will  rarely  be  overlooked.  Injury  of  the  radial  and 
ulnar  arteries  jeopardizes  the  circulation  of  the  entire  hand,  but  is  not 
an  indication  per  se  for  amputation.  The  author  has  seen  the  collateral 
circulation  so  established  by  elevation,  application  of  warmth,  and 
omission  of  all  compressing  bandages  or  splints  that  the  hand  was  saved. 
If  the  part  is  crushed  throughout  its  circumference,  there  is  often  no 
prospect  of  its  preservation. 

Shot- wounds  may  be  equally  unfavorable  if  the  discharge  into  the 
hand  was  at  close  range,  for  then  the  explosive  action  of  the  gases 
damages  the  circulation  more  than  the  circumscribed  action  of  the 
projectile. 

The  course  of  compound  injuries  of  the  wrist  depends  essentially  upon 
the  extent  of  the  accompanying  infection.  Suppuration  extending 
throughout  the  entire  joint  was  and  is  feared  at  the  present  time  as 
much  as  infection  of  the  ankle-joint.  The  infection  spreading  along 
the  damaged  tendon-sheaths  may  endanger  the  limb  or  life  itself. 

Treatment. — The  treatment  should  therefore  insure  drainage,  as  some 
discharge  is  always  to  be  expected.  The  injured  hand  should  be 
cleaned  and  sterilized  as  soon  as  possible  after  the  injury;  this  is  often 
a  difficult  task.  After  scrubbing  the  skin  well  with  soap  and  warm 
water  the  interdijrital  folds  and  the  nails  are  carefullv  cleaned.  The 
skin  is  further  cleaned  with  ether,  turpentine,  or  tincture  of  green  soap; 
the  entire  process  frequently  requires  half  an  hour;  the  cleansing  of  the 
wound  follows.  The  circulation  and  innervation  are  first  tested;  all 
displacements  are  then  reduced,  necrotic  tissues  excised,  the  tendons 
and  nerves  sutured,  and  by  retention  sutures  the  tissues  restored  as  far 
as  possible  to  their  normal  relation.  The  wound  should  be  left  open 
wherever  it  is  desirable  to  keep  the  parts  under  inspection  or  where 
discharge  may  be  expected  from  necrosed  tissue.  The  cavity  may  be 
packed  loosely  with  sterile  gauze  or  drainage-tubes  inserted.  The  wound 
is  then  best  covered  with  a  dry  aseptic  dressing,  the  limb  immobilized 
upon  a  hand-board,  or  pasteboard,  or  light  plaster  splint,  and  suspended 
for  several  days  by  v.  Volkmann's  method.  If  infection  occurs,  it 
should  be  treated  according  to  the  directions  already  given:  in  the  event 
of  phlegmonous  inflammation  the  wounds  are  enlarged  and  drainage 
obtained  wherever  retention  is  imminent.  Temperature  and  local  pain 
Vol.  III.— 20 


306  INJURIES  OF  THE  WRIST  AND  HAND. 

are  the  best  indications  for  the  nature  of  the  treatment.  If  the  course 
is  uninterrupted,  the  author  leaves  the  first  dressing  undisturbed  for 
from  six  to  eight  days,  changing  it  earlier  only  if  there  is  throbbing 
and  tense  pain  in  the  wound  with  an  afternoon  temperature  above 
101°  to  102.5°  F.     The  same  rules  apply  equally  to  shot-wounds. 

Resection  will  be  necessary  primarily  if  the  bones  are  badly  damaged, 
and  secondarily  for  suppuration  with  insufficient  drainage.  The  limits 
of  conservative  treatment  should  be  made  as  wide  as  possible,  but  the 
mechanical  possibility  should  not  be  overstepped:  suppuration  in  the 
joint  will  always  demand  the  sacrifice  of  one  or  more  carpal  bones  to 
insure  speedy  and  certain  recovery.  General  rules  cannot  be  given; 
experience  and  objective  analysis  will  determine  the  mode  of  procedure. 
Removal  of  the  articular  ends  of  the  radius  and  ulna  should  be  avoided 
if  possible.  (See  chapter  on  Resections.)  Ankylosis,  more  or  less  firm, 
is  the  usual  result  of  every  protracted  suppuration  in  the  wrist.  The 
prognosis  is  generally  doubtful  as  to  function  on  account  of  the  involve- 
ment of  the  tendons  and  tendon-sheaths;  not  only  stiffness  in  the  joint, 
but  also  severe  limitation  of  the  finger  movements  usually  follow  the 
local  suppuration ;  the  earning-efficiency  of  the  patient  is  often  perma- 
nently compromised. 


FRACTURE  OF  THE  METACARPALS  AND  PHALANGES. 

Fracture  of  the  Metacarpals.— v.  Brans,  among  553  fractures  of  the 
bones  of  the  hand,  gives  70  as  involving  the  metacarpals;  9  in  the  second, 
23  in  the  third,  22  in  the  fourth,  10  in  the  fifth,  and  the  remaining  G 
in  the  first  and  sixth  decades  of  life. 

According  to  Malgaigne,  women  are  rarely  affected  by  this  injury 
(1  in  16).  The  author  has  seen  only  one  female  patient  in  the  entire 
material  of  his  polyclinic.  Formerly  regarded  as  a  relatively  rare  injury, 
the  number  of  cases  has  increased  considerably  since  the  use  of  the 
.r-ray.  There  is  no  demonstrable  predisposition  of  any  single  bone. 
Certainly  the  first  metacarpal  does  not  take  the  place  assigned  to  it  by 
Malgaigne. 

The  fracture  may  occur  in  various  ways:  most  frequently  the  cause 
is  a  blow  (machinery),  shot,  or  a  fall  upon  the  dorsum  of  the  hand; 
the  direction  of  the  force  is  thus  more  or  less  perpendicular  to  the  long 
axis  of  the  bone  and  produces  an  angular  deformity  toward  the  volar 
surface.  Less  commonly  it  is  a  blow  upon  the  metacarpophalangeal 
joint,  due  to  a  fall  or  collision  with  a  solid  body,  acting  in  the  direction 
of  the  axis  of  the  shaft;  this  presupposes  that  the  hand  is  clenched. 
(Hamilton,  several  own  observations.)  Dupuytren  reports  a  rare  frac- 
ture in  wrestlers,  the  metacarpals  being  bent  backward  when  the  hands 
are  interlocked  in  the  effort  to  throw  the  opponent.  Whereas  by  direct 
violence  the  fracture  can  occur  at  any  point,  the  break  resulting  from 
indirect  violence  is  almost  always  oblique  or  a  long  fissure-fracture  in 
the  middle  of  the  shaft.    Infraction  of  the  neck  and  crushing  of  the  head 


PLATE    IX 


FIG.    1. 


Fracture  of  Carpal  Scaphoid.     (Stimson. 


FIG.    2. 


Fracture    of   the   Third,    Fourth,    and    Fifth    Basal 
Phalanges.      (Solley.) 


FRACTURE  OF  THE  METACARPALS  AND  PHALANGES.     307 


Fig.  205. 


are  not  rare,  and  from. the  history  are  caused  by  violence  in  the  axis 
of  the  bone. 

Traumatic  separation  of  the  epiphysis  <>f  the  metacarpals,  designated 
by  Bardenheuer  as  a  frequent  injury  in  childhood,  the  author  has  seen 
in  only  a  few  instances;  likewise  fracture  of  the  base  of  the  first  meta- 
carpal (stave  of  thumb,  Bennet's  fracture),  recently  reported  by  Prichard 
and  Beatson,  is  easily  mistaken  for  sprain  of  the  thumb  and  does  not 
belong  among  the  "frequent"  injuries. 

The  displacement  is  often  hardly  recognizable  on  account  of  the 
position  of  the  bone  between  the  small  muscles  of  the  hand;  but  it  may 
be  so  pronounced  that  the  head  projects  proximally  J  inch  beyond  the 
adjacent  metacarpals.  The  .r-ray  always  shows  the  fracture-line  if  the 
rays  penetrate  in  the  proper  direction,  although  deception  is  possible. 
The  fracture-line  is  usually  proximal-dorsal  to  distal-volar;  the  lateral 
displacement  is  slight,  and  if  the  fracture-line  is  long  and  the  illumina- 
tion is  dorsoventral,  the  line  may  not  be  seen.  In  the  same  manner  in 
transverse  (radio-ulnar)  illumination  the  fracture-line  may  be  concealed 
by  the  adjacent  metacarpals;  accurate  information  is  then  obtained  by 
semipronating  the  hand.  The  distal  fragment,  especially  the  head, 
usually  projects  somewhat  into  the  palm,  the  projecting  proximal  edge 
of  the  distal  fragment  being  recognizable  on  the  dorsum,  together  with 
pain  on  pressure  or  crepitus.  If  there  is 
much  extravasation — which  is  uncom- 
mon— the  signs  on  palpation  may  be  less 
pronounced  than  the  localized  point  of 
tenderness.  False  motion  can  generally 
be  elicited  by  proper  manipulation  of  the 
fragments.  Exceptionally  the  fixed  point 
of  tenderness  will  be  the  only  symptom 
except  the  swelling  produced  by  the  ex- 
travasation. 

If  the  head  is  broken  off  or  crushed, 
one  usually  finds  it  or  the  pieces  project- 
ing into  the  palm,  the  proximal  part  of 
the  shaft  projecting  on  the  dorsum.  The 
first  phalanx  of  the  finger  sinks  into  the 
palm  with  the  head,  especially  in  the  case 
of  the  fifth  metacarpal,  and  may  resemble 
volar  dislocation  of  the  finger.  Crepitus 
is  always  present  and  the  test  of  the 
joint-function'  confirms  the  diagnosis. 

Treatment. — The  symptoms  may  be  so 
slight  that  the  fracture  heals  satisfactorily 
without  special  treatment.  In  other  cases 
an  underestimation  of  the  injury  may 
result    in    protracted    disability    of    the 

affected  finger  or  even  the  entire  hand.    It  is  therefore  advisable,  if  dis- 
placement is  evident,  to  reduce  it  by  traction  upon  the  finger  and  pressure 


Coaptation  splints  for  fracture  of  the 
metacarpals.     (C.  Beck.) 


308  INJURIES  OF  THE  WRIST  AND  HAND. 

upon  the  fragment,  and  to  immobilize  in  a  splint.  For  this  purpose  a 
dorsal  and  a  volar  splint  have  been  applied  (Albert,  Konig)  and  the 
pressure  upon  the  dorsum  increased  by  appropriate  padding  (Malgaigne). 
The  method  of  Carl  Beck  is  illustrated  in  Fig.  205.  Bardenheuer 
employed  continuous  traction,  and  was  pleased  with  the  results.  If 
the  displacement  is  still  pronounced  after  attempted  reduction  by 
forcible  traction,  the  author  applies  a  splint  corresponding  to  a  double 
inclined  plane,  the  finger  being  fastened  with  adhesive  plaster  to  the 
shorter  incline  and  padding  placed  under  the  head  of  the  metacarpal 
if  necessary.  Anyone  can  convince  himself  that  the  fracture  is  not  to 
be  regarded  indifferently  from  the  prognostic  point  of  view  by  follow- 
ing it  to  the  time  of  complete  functional  return.  Although  the  splint 
may  be  removed  at  the  tenth  to  the  fourteenth  day,  the  full  earning- 
efficiency  may  not  be  restored  till  the  third  or  fourth  week  even  in  favor- 
able cases.  Many  require  a  longer  period,  and  regain  the  full  power 
and  full  use  of  the  hand  and  fingers  and  tendons  without  pain  only  by 
regular  massage  and  passive  and  active  motion.  Even  the  lack  of 
strength  and  dull,  weakening  pain  may  impair  the  full  earning-efficiency 
for  months.  Comminution,  although  rare,  can  produce  aseptic  necrosis 
of  small  fragments  in  the  metacarpal  as  in  the  metatarsus;  the  incom- 
plete recovery  troubles  the  patient  and  justifies  secondary  removal  of 
the  splinters. 

Fracture  of  the  Phalanges. — According  to  v.  Brims,  fracture  of  the 
phalanges  constitutes  5  per  cent,  of  all  fractures;  directly,  it  is  rarely 
subcutaneous,  but  more  frequently  compound.  The  fracture  is  usually 
indirect,  but  is  not  common  on  account  of  the  mobility  and  short- 
ness of  the  bone.  Separation  of  the  epiphysis  is  rare.  In  subcu- 
taneous fracture  the  traction  of  the  flexors  produces  angular  deformity 
with  the  point  of  the  angle  toward  the  dorsum,  and  shortening.  The 
fracture-line  usually  corresponds  to  that  of  the  metacarpal,  proximal- 
dorsal  to  distal-volar.  Exceptionally  there  may  be  lateral  displacement 
of  the  distal  fragment,  or  dorsal  displacement  from  predominating 
traction  of  the  extensors. 

Diagnosis. — The  diagnosis  is  simple.  Crepitus  is  constant.  Partial 
or  complete  separation  of  the  epiphysis  or  partial  fracture  of  the  latter 
may  simulate  dislocation.  The  phalanx  is  then  curved  somewhat  toward 
the  palm,  as,  for  example,  in  fracture  of  the  dorsal  part  of  the  epiphysis; 
the  phalanx  is  freely  movable;  there  may  be  crepitus  in  the  joint.  Longi- 
tudinal fracture  is  rare  and  is  recognizable  later  by  the  involvement  of 
the  joint.  (Kronlein.)  Forcible  flexion  may  cause  a  piece  of  the  base 
of  the  first  phalanx  to  be  torn  off  by  the  traction  of  the  extensor  tendon. 
(Busch.)  The  author  has  seen  two  such  cases;  the  separated  fragment 
of  the  end-phalanx  lies  over  the  second  interphalangeal  joint,  or  may 
even  be  drawn  up  into  the  palm;  flexion  of  the  end-phalanx  is  lost; 
there  is  pain  in  the  joint  on  passive  motion. 

Treatment. — As  there  is  not  infrequently  a  tendency  toward  rotation 
at  the  site  of  fracture,  in  addition  to  the  tendency  to  displacement,  the 
rotation  should  be  prevented  by  a  spiral  of  adhesive  plaster,  over  which 


DISLOCATION  OF  METACARPUS  AND  PHALANGES.         309 

a  light  volar  plaster  splint  is  applied  with  the  fingers  slightly  flexed, 
the  splint  extending  from  the  wrist  to  the  finger-tips.  Although  such 
extensive  immobilization  may  seem  a  hit  precise,  it  is  advisable  for 
people  of  the  laboring-class. 


DISLOCATION  OF  THE  METACARPUS  AND  OF  THE  PHALANGES. 

Dislocation  of  the  Carpometacarpal  Joint.— The  earpometacarpal 
dislocation  is  one  of  the  rarest  of  dislocations.  Bnrk  has  recently  col- 
lected 24  instances  of  dislocation  of  the  metacarpals,  with  the  exception 
of  the  thumb,  and  added  a  case  seen  in  v.  Brims'  clinic.  Dislocation  of 
the  entire  metacarpus  is  very  rare,  as  the  ligaments  between  the  carpals 
and  metacarpals  are  very  firm.  Among  Burk's  cases  there  were  4 
volar,  3  dorsal,  and  1  lateral  dislocation,  most  of  the  metacarpals  being 
displaced  dorsally  (second,  third,  and  fourth),  only  one  (the  fifth)  toward 
the  palm.  The  cause  was  always  severe  direct  or  indirect  violence; 
in  the  latter  case  by  hyperflexion,  hyperextension,  or  lateral  compres- 
sion of  the  metacarpus.  The  characteristic  symptoms  are  shortening 
of  the  hand  and  fingers,  a  transverse  bony  projection  upon  the  dorsum 
or  in  the  palm,  and  limited  flexion  of  the  fingers. 

Dislocation  of  one  or  more  metacarpals  is  usually  dorsal  (14  dorsal, 
2  volar,  Bnrk).  Dorsal  dislocation  is  usually  complete;  subluxation  is 
the  rule  in  the  volar  form.  Isolated  dislocation  of  the  first  metacarpal 
is  most  common;  it  is  usually  incomplete,  but  may  be  volar,  dorsal, 
complete,  incomplete,  or  habitual.  Incomplete  dorsal  dislocation  of  the 
first  metacarpal  presupposes  hyperflexion  and  adduction.  In  a  number 
of  cases  there  was  apparently  simultaneous,  backward  pressure  upon 
the  head.  A  further  cause  may  be  a  fall  upon  the  thenar  eminence  near 
the  outer  end  of  the  metacarpal  lever-arm,  or  near  the  head.  The  author 
has  seen  3  instances  of  voluntary  subluxation  of  the  first  metacarpal 
backward  and  somewhat  outward ;  2  were  in  children  eleven  and  thirteen 
years  old,  and  1  in  a  man  of  twenty-three.  In  each  instance  the  displace- 
ment could  be  produced  by  flexion  and  maximal  adduction  of  the  meta- 
carpal; it  occurred  with  a  snap  and  slid  back  into  its  proper  place  against 
the  trapezium  on  abducting  and  extending. 

Dislocation  of  the  Phalanges  (except  of  the  Thumb). — Among 
19S  dislocations  Weber  reports  20  of  the  fingers;  among  400  dislocations 
in  v.  Langenbeck's  clinic  Kronlein  reports  27  of  the  metacarpophalan- 
geal joints  (7  per  cent.).  The  greater  frequency  of  metacarpophalangeal 
dislocation  compared  with  carpometacarpal  is  explained  by  the  greater 
range  of  motion  in  the  former  joint,  and  by  the  fact  that  in  use  and 
during  the  injury  the  corresponding  finger  acts  as  a  whole,  the  force 
accordingly  being  applied  through  a  longer  lever-arm. 

Two  strong  lateral  ligaments  on  the  tight  capsule  of  the  joint  insure 
the  hinge  movement  about  the  transverse  (radio-ulnar)  axis;  during 
extension  they  are  slightly  relaxed,  and  therefore  allow  slight  lateral  dis- 
placement of  the  phalanx  upon  the  metacarpal.   Limitation  of  flexion  and 


310 


INJURIES  OF  THE  WRIST  AND  HAND. 


Fig.  206. 


extension  depends  upon  the  resistance  of  the  capsule  and  the  reinforcing 
transverse  fibres  stretched  between  the  lateral  ligaments.  These  trans- 
verse fibres  form  the  pulleys  over  which  the  tendons  are  able  to  carry 
out  the  movements  of  the  finger-joints  in  an  angular  position,  and  are 
therefore  essential  for  the  use  of  the  fingers.  In  the  thumb  they  are 
reinforced  by  the  sesamoid  bones  (of  which  the  inner  is  small  and  solid, 
the  outer  broader  and  less  compact),  hence  the  term  ligamenta  inter- 
sesamoidea.  The  fibres  running  from  the  transverse  ligaments  to  the 
dorsum  are  weaker  in  proportion  to  the  lesser  demand  made  upon  them. 
The  average  normal  range  of  flexion  is  90  degrees,  of  extension  30 
degrees;  this  range,  particularly  that  of  extension,  is  often  increased 
considerably  in  children,  in  pianists,  saddlers,  and  mechanics,  frequently 
as  the  result  of  a  steady  occupation.  There  are  many  women,  and 
children  of  both  sexes,  in  whom  these  bilateral  ligaments  are  so  relaxed 
that  the  usually  limited  lateral  displacement  can  be  increased  passively 
from  one-third  to  one-half  the  width  of  the  joint.  Habitual  or  volun- 
tary subluxation  is  then  not  infrequent. 

Dorsal  displacement  of  the  first  phalanx  upon  the  metacarpal  may 
be  designated  as  a  typical  phalangeal  dislocation;  it  is  very  common 
in  the  thumb,  and  for  this  reason  will  be  con- 
sidered separately  on  account  of  its  practical 
significance.  Interphalangeal  dislocation  is  rare, 
and  is  usually  dorsal.  The  cause  is  almost  al- 
ways hyperextension.  (Fig.  206.)  Volar  dislo- 
cation is  even  more  rare;  Huter  questions 
whether  it  is  caused  by  maximal  flexion.  The 
accompanying  illustration  (Fig.  206)  shows  an 
old  unreduced  dislocation  of  the  end-phalanx. 
The  position  of  the  finger  is  characteristic:  the 
affected  joint  is  extended,  the  proximal  joint 
flexed,  and  the  finger  shortened;  in  a  recent  case 
there  was  an  actual  shortening  of  -J-  inch;  in  the 
old  case  the  middle  phalanx  was  increased  al- 
most h  inch  in  length  as  the  result  of  the  growth 
caused  secondarily  by  the  pressure.  This  illus- 
tration is  introduced  because  even  at  the  present 
time  the  importance  of  dislocation  of  the  pha- 
langes is  underestimated  or  not  even  considered. 
Lateral  dislocation  has  also  been  seen.  (Mal- 
gaigne,  Riedinger,  own  observation.)  If  part  of 
the  lateral  ligament  remains  intact  the  phalanx 
may  be  dislocated  and  rotated  in  the  direction  of  the  ligament.  The 
author  has  repeatedly  seen  such  rotation  in  cases  of  complete  disloca- 
tion of  the  joint-surfaces.  Fracture  of  the  head  of  the  proximal  bone 
(metacarpal  or  phalanx)  is  easily  mistaken  for  dislocation. 

Treatment. — The  rule  to  reduce  in  the  line  in  which  the  violence 
produced  the  dislocation  applies  here;  so  it  is  advisable  in  dorsal  dis- 
location to  hyperextend,  in  the  volar  form  to  hyperflex.    This  is  usually 


Old  dislocation  of  end-phalanx 
of  index  finger  with  secondary 
elongation  of  the  second  pha- 
lanx from  the  irritation. 


PLATE   X. 


Fresh  Dorsal  Dislocation  of  the  Thumb.     (Stimson.) 


DISLOCATION  OF  METACARPUS  AND  PHALANGES. 


311 


easy  and  requires  no  particular  appliances.  If  the  dislocated  phalanx 
is  simultaneously  rotated,  it  is  abducted  in  the  direction  of  the  still  intact 

portion  of  the  ligament.  For  every  dislocation  the  author  recommends 
immobilization  from  five  to  seven  days,  followed  by  active  motion. 

Dislocation  of  the  Thumb. — The  thumb  is  more  frequently  dislocated 
than  any  other  finger;  according  to  Gurlt,  the  lesion  constitutes  5  per 
cent,  of  all  dislocations.  Complete  dislocation  is  estimated  by  Malgaigne 
at  3  per  cent.  The  injury  is  confined  almost  exclusively  to  middle-aged 
men;  single  instances  in  children  five  to  twelve  years  old  have  been 
observed  by  Malgaigne,  Blandin,  Bardenheuer,  and  others. 

As  Bardenheuer  says,  the  diagnostic  errors  and  difficulty  of  reduction 
are  responsible  for  the  unfortunate  reputation  of  dislocation  of  the 
thumb. 

Mechanism. — The  causes  discussed  previously  in  reference  to  disloca- 
tion of  the  fingers  apply  here.    Surgeons  are  indebted  to  Farabeuf  for 

Fig.  207. 


Simple  complete  dislocation  of  the  thumb,  outer  side.      (Farabeuf.) 

one  of  the  best  descriptions  of  the  mechanism  of  dislocation  of  the 
thumb.  According  to  his  classification,  one  may  distinguish  practically: 
a)  luxatio  incompleta,  (b)  luxatio  completa,  (c)  luxatio  complexa.  In 
this  classification  the  position  of  the  sesamoid  bones  is  decisive:  in  incom- 
plete dislocation  they  still  lie  at  the  joint-surface  of  the  metacarpal;  in 
the  complete  form  they  are  displaced  backward;  in  the  complex  form 
they  are  reversed  and  interposed.  In  (a)  the  base  the  phalanx  is  still 
partially  in  contact  with  the  joint-surface  of  the  metacarpal;  in  (b)  and  (c) 
it  is  always  completely  dislocated.  A  sudden  blow  received  upon  the  pal- 
mar surface  of  the  thumb  hyperextends  the  same;  the  posterior  border  of 
the  base  of  the  first  phalanx  presses  against  the  back  of  the  metacarpal, 
the  flexor  ligaments  are  put  on  the  stretch,  are  torn  by  the  continuation 
of  the  force — almost  always  at  their  insertion  on  the  metacarpal — so  that 
the  greater  part  of  the  volar  ligaments  remain  attached  to  the  phalanx 
and  slip  backward  with  it,  usually  accompanied  by  the  sesamoid  bones. 


:i2 


INJURIES  OF  THE  WRIST  AND  HAND. 


The  head  of  the  metacarpal,  forced  out  through  the  volar  rent,  becomes 
button-holed  at  its  neck  in  the  ring  formed  by  the  retracting  parts  of  the 
capsule.  The  tightness  of  this  ring  is  occasionally  increased  by  the 
simultaneous,  stronger  contraction  of  the  heads  of  the  flexor  brevis. 
The  lateral  ligaments  are  torn  partially  or  completely,  the  stronger  one 
on  the  inner  side  holding  out  the  longest.  If  the  latter  is  not  torn,  only 
the  outer  sesamoid  bone  may  be  displaced  backward,  whereas  the  inner  or 
ulnar  bone  may  be  forced  inward  with  the  tendon  of  the  flexor  longus 
pollicis.  If  the  inner  ligament  is  torn  partially  or  completely,  the  inner 
sesamoid  bone  will  lie  upon  the  back  of  the  metacarpal.  The  fibres 
of  the  flexor  brevis  may  be  torn,  the  abductor  brevis  usually  remains 
intact,  the  adductor  is  displaced.  At  the  moment  of  dislocation  the 
tendon  of  the  flexor  longus  pollicis  usually  slips  to  the  inner  side  of  the 
head  of  the  metacarpal  and  may  be  hooked  over  its  neck.  (Frank, 
Ilelferich.)  The  chief  hindrances  to  reduction  result  from  the 
position  of  the  structures  about  the  joint:  interposed  capsule  (Pail- 
loux)  with  one  or  both  sesamoid  bones  and  the  flexor  longus  pollicis 
slipped  or  hooked  over  the  metacarpal.  The  hyperextension  of  the 
phalanx  is  frequently  followed  by  flexion  caused  by  muscular  traction; 
if  the  flexion  toward  the  palm  is  increased  by  pressure  upon  the  phalanx, 
the  base  of  the  bone  tears  off  the  already  lacerated  ligament;  the  latter 
curls  up  backward,  the  sesamoid  bone  rotates  and  then  lies  reversed 
between  the  base  and  the  metacarpal  (luxatio  complexa). 

Fig.  208. 


Complex  dislocation.    (Farabeuf.) 


Symptoms. — From  the  foregoing  the  symptoms  should  be  clear.  On 
inspection  the  chief  variations  depend  upon  whether  the  hyperextension 
still  exists,  the  thumb  being  at  a  right  angle  to  the  metacarpal;  or  whether 
the  subsequent  traction  of  the  flexors  has  brought  the  dislocated  phalanx 
approximately  into  a  position  parallel  to  the  metacarpal.  (Fig.  208.)  In 
the  former  case,  aside  from  the  abnormal  position  of  the  thumb,  the 
most  striking  thing  is  the  bulging  of  a  hard  rounded  body  in  the  palm, 
the  head  of  the  metacarpal,  which  may  be  mistaken  for  the  base  of  the 
phalanx.    If  flexion  has  taken  place,  besides  the  head  of  the  metacarpal 


DISLOCATION  OF  METACARPUS  AND  PHALANGES.        313 

being  felt  in  the  palm,  the  small  articular  surface  of  the  phalanx  is  fell 
on  the  dorsum  like  a  small  disk,  analogous  to  the  articular  surface  of 

the  head  of  the  radius  in  complete  backward  dislocation  of  the  forearm. 
If  the  flexion  of  the  phalanx  is  increased  by  pressure,  its  joint-surface 
can  be  felt  so  plainly  that  it  can  scarcely  he  mistaken  by  the  examiner. 
Comparing  the  backs  of  the  two  thumbs  shows  the  shortening  of  the 
metacarpal  axis,  \  to  ■',  inch.  Active  and  passive  extension  is  impossible. 
The  second  phalanx  is  almost  always  flexed  upon  the  extended  first 
phalanx.    (Fig.  207.) 

Treatment. — Reduction  is  usually  easy  if  the  general  rule  is  followed 
to  reduce  a  dislocation  in  the  same  way  in  which  it  is  produced,  namely, 
to  begin  with  hyperextension  (maximal  dorsal  flexion).  Force  is  not 
necessary:  hyperextension  of  the  thumb,  pressure  from  behind  against 
the  base  of  the  first  phalanx,  then  pushing  it  forward  with  simultaneous 
flexion  of  the  thumb.  Sometimes,  particularly  if  the  internal  lateral 
ligament  is  intact  and  the  phalanx  is  adducted,  it  is  well  to  combine  gentle 
rotation  about  the  intact  ligament  as  a  centre  with  the  above-mentioned 
manipulation.  The  unequally  wide  gaping  of  the  joint-struetures  from 
each  other  may  allow  the  parts  to  be  interposed  on  the  outer  side,  the 
inner  side  remaining  free. 

The  most  important  of  the  hindrances  to  reduction  mentioned  is  the 
interposition  of  +he  capsule,  sometimes  with  one  or  both  sesamoid  bones. 
Whereas  in  incomplete  dislocation  the  author  attempts  to  push  the 
sesamoid  bones  and  the  base  of  the  phalanx  downward  and  forward,  if 
there  is  any  interposition  it  is  well  to  begin  by  pulling  forcibly  upon 
the  thumb  in  the  direction  of  the  dislocation;  the  interposed  parts  are 
usually  freed  in  this  manner.  By  increasing  this  traction  the  hyper- 
extension is  increased  to  a  right  angle  or  further  and,  allowing  the 
dorsal  edge  of  the  base  of  the  phalanx  to  rest  against  the  dorsum  of  the 
metacarpal,  the  anterior  border  of  the  phalanx  is  levered  up  so  that 
the  phalanx,  ligament,  and  sesamoid  bones  may  be  pushed  forward; 
the  joint-surface  of  the  phalanx  is  then  pushed  forcibly  and  gradually 
forward  upon  the  joint-surface  of  the  metacarpal  while  flexing.  The 
metacarpal  must  meanwhile  be  held  firmly,  the  end-phalanx  slightly 
flexed  to  relax  the  flexor  longus  pollicis. 

The  author  desires  to  warn  against  the  use  of  all  sharp  reduction 
instruments;  Liier's  instrument  is  often  described  and  illustrated.  The 
ideal  instrument  is  the  hand  of  the  operating  surgeon  guided  by  the 
knowledge  of  the  mechanism  of  injury.  Assuming  that  the  hindrance 
is  caused  by  the  tendon  of  the  flexor  longus  pollicis  winding  around  the 
neck  of  the  metacarpal  on  its  inner,  or  ulnar,  side  (Ballingall,  Dittel, 
Lauenstein,  and  Helferich),  the  thumb  may  be  adducted  slightly  and 
rotated  to  the  right  (clock- wise) .  This  grip  aids  every  difficult  reduction, 
as  the  tendon,  without  being  itself  the  actual  hindrance,  may  by  its 
tension  press  the  torn  anterior  part  of  the  capsule  between  the  surfaces 
of  the  joint.  Relaxing  the  tension  of  the  tendon  makes  the  interposed 
parts  of  the  capsule  movable  or  yielding.  The  tense  lateral  ligaments 
also,  if  partially  intact,  may  hold  the  base  of  the  phalanx  behind  the 


314  INJURIES  OF  THE  WRIST  AND  HAND. 

head  of  the  metacarpal;  they  may  be  gradually  relaxed  by  increasing  the 
dislocation. 

If  reduction  is  not  possible,  the  patient  should  be  anaesthetized; 
if  still  unsuccessful,  in  spite  of  thorough  trial  of  the  above  procedure, 
nothing  remains  but  operation.  The  author  would  recommend  imme- 
diate operative  reduction  in  all  cases  resisting  the  above  technic.  The 
author  has  never  had  any  experience  with  subcutaneous  tenotomy  of 
one  or  more  tendons  and  division  of  all  tense  parts.  This  procedure  is 
no  longer  in  accord  with  the  demands  of  modern  surgery;  namely,  fullest 
possible  inspection,  least  possible  hemorrhage,  and  asepsis.  In  the 
given  case  a  radial  lateral-incision  is  most  advisable:  1.  Because  the 
future  scar  does  not  interfere  with  the  use  of  the  hand.  2.  Because  the 
axis  of  the  metacarpal  is  exposed  easily  without  hemorrhage  or  division 
of  the  muscles.  3.  Because  the  most  frequent  unsurmountable  hindrance 
is  the  outer  sesamoid  bone  and  this  is  thus  exposed.  The  soft  parts 
are  drawn  well  apart  with  sharp  retractors,  the  ligaments  loosened,  dis- 
placed portions  of  ligaments  excised,  and  the  sesamoid  bone  removed. 
By  slightly  adducting  the  thumb  the  surgeon  can  obtain  a  good  view 
of  all  the  parts,  can  remove  all  hindrances,  and  after  suturing  the  capsule 
with  two  or  three  sutures  of  fine  silk,  may  completely  close  the  wound. 
The  splint  should' include  the  first  and  end-phalanges  of  the  thumb 
slightly  flexed.  Motion  should  not  be  begun  before  the  fourteenth 
day. 

In  old  cases  (after  three  to  six  months)  resection  of  the  head  of  the 
metacarpal  may  be  necessary.  Shortening  of  the  metacarpophalangeal 
axis  is  then  desirable,  as  otherwise  it  is  not  possible  to  maintain  the  cor- 
rection with  certainty.  The  function  is  incomparably  better  than  before 
the  operation,  but  rarely  restores  the  normal  excursion  of  flexion  and 
extension  essential  for  a  good  grip.  Painful  sensations  during  motion 
may  last  for  a  long  while. 

Volar  dislocation  of  the  first  phalanx  of  the  thumb  is  very  rare,  and 
is  easily  explained  by  the  infrequency  of  the  line  of  force  required, 
namely,  maximal  flexion.  (Lenoir,  O.  Weber,  Hamilton.)  Force  pro- 
ducing abduction  or  adduction  may  also  be  concerned  (Meschede) ;  the 
thumb  is  usually  found  at  the  same  time  in  a  position  of  radial  or  ulnar 
abduction.  The  extensor  tendons  can  presumably  be  interposed.  Bessel- 
Hagen  has  seen  pure,  radial  lateral  dislocation  and  explained  its  origin. 

y 
WOUNDS  OF  THE  HAND  AND  FINGERS. 

Whereas  the  judgment  of  simple  wounds  of  the  hand  and  fingers  makes 
little  claim  upon  the  surgeon,  the  complicated  wounds,  especially  those 
due  to  the  highly  developed,  modern,  mechanical  industries,  make  large 
demands  upon  his  judgment  and  technical  ability. 

Incised  and  Stab-wounds. — Owing  to  the  favorable  conditions  of 
the  circulation  of  the  hand  and  fingers,  these  wounds  recover  under 
simple  treatment;  cleansing  the  wound  area,  freshening  the  edges  if 


WOUNDS  OF  THE  HAM)  AND  FINGEBH.  315 

soiling  or  infection  is  probable,  and  a  few  sutures,  sterile  or  bichloride 
dressing,  and  small  pasteboard  splints,  are  sufficient.  Recovery  ma) 
be  uneventful  even  if  the  wound  involves  a  hone  or  a  joint,  or  part  of  a 
finger  has  been  cut  off.  From  the  author's  experience  and  that  of  others 
there  are  reasons  for  hoping  that  completely  severed  portions  of  fingers, 
if  sutured  in  place  and  bandaged  lightly  within  a  tew  hours  after  the 
injury,  may  grow  on  again.  Division  of  the  tenden  is  often  overlooked 
in  small  incised  wounds.  The  earlier  it  is  sutured, granting  that  then 
is  no  infection,  the  more  favorable  will  be  the  result.  (See  Technic  of 
Suture  of  the  Tendons,  page  282.) 

Gunshot- wounds. — The  shot-wounds  resulting  so  often  from  acci- 
dental discharge  of  a  revolver,  rifle,  or  shotgun  are  usually  simple  with 
reference  to  treatment:  the  bullet  or  shot  is  removed  without  difficulty 
if  accessible.  The  .r-ray  gives  accurate  topographical  information,  an  im- 
portant consideration  if  there  are  several  bodies.  An  extensive  discharge 
of  fine  shot  lies  palpably  beneath  the  skin,  and  its  removal  is  apparently 
possible  through  a  superficial  incision;  lateral  illumination  with  the 
it-ray  shows  the  error  and  warns  of  the  necessary  care  with  reference 
to  the  deep-seated  shot.  Bullets  often  heal  in  without  causing  disturb- 
ance. Shot-wounds  of  the  palm,  which  are  apt  to  carry  infectious  material 
with  them,  more  often  cause  infection;  the  author  treats  them  on  general 
principles.  Free  incision  is  indicated  primarily  only  for  marked  hemor- 
rhage or  comminution  of  the  bone. 

Puncture- wounds. — Puncture-wounds  give  a  widely  varying  prog- 
nosis, and  it  is  often  difficult  to  decide  as  to  their  treatment.  Even  the 
apparently  harmless  sort  on  the  back  of  the  finger  can  easily  penetrate 
into  the  joint;  those  on  the  palmar  surface  not  infrequently  introduce 
infectious  material  into  one  of  the  tendon-sheaths  with  all  the  conse- 
quences of  infection.  Puncture-wounds  in  the  palm  caused  by  splinters 
of  glass  or  cutting  metal  instruments  are  interesting  on  account  of  the 
profuse  hemorrhage.  The  superficial  palmar  arch  is  easily  injured  and 
hemorrhage  from  the  deep  arch  is  not  rare.  In  all  these  cases  it  is  the 
rule  to  obtain  free  inspection  of  the  source  of  hemorrhage  by  enlarging 
the  wound  and  separating  the  edges  with  sharp  retractors;  then  to  ligate. 
Where  the  hemorrhage  is  profuse,  if  the  Esmarch  is  applied,  on  releasing 
it  the  injured  vessel  is  quickly  found.  Here  and  there  one  finds  the 
application  of  styptics  recommended,  especially  chloride  of  iron  or 
Penghawar  Djambi.  Lack  of  assistance  and  restlessness  of  the  patient 
may  excuse  their  use,  but  the  uncertainty  of  their  action  may  lead  to 
greater  difficulty  in  checking  the  hemorrhage,  for  the  chloride  of  iron, 
in  coagulating  the  albumin,  obscures  the  anatomical  details,  and  if 
secondary  bleeding  demands  interference,  the  field  is  less  clear  than 
before.  In  such  cases  the  author  would  recommend  firm  application 
of  an  aseptic  dressing  on  the  bleeding  spot  and  suspension  of  the  limb, 
as  advised  by  v.  Volkmann.  The  arm  should  be  placed  in  a  well-padded 
wood,  tin,  or  pasteboard  splint,  the  patient  made  to  lie  down,  and  the 
arm  well  elevated  by  means  of  a  suspension  apparatus  (v.  Volkmann's), 
or  an  improvised  upright  with  a  loop  or  pulley,  rope,  nail  in  the  wall,  etc. 


316  INJURIES  OF  THE  WRIST  AND  HAND. 

Foreign  Bodies. — Small  foreign  bodies  can  almost  always  be  palpated 
with  the  end  of  a  probe;  larger  bodies  are  sought  through  the  path  of 
entrance.  In  the  former  case,  however,  with  insufficient  anaesthesia, 
larger  or  smaller  exploratory  incisions  are  frequently  made  about  the 
wound  without  finding  the  foreign  body.  The  rule,  to  make  every 
exploration  of  foreign  bodies  bloodless  and  with  local  anaesthesia,  rarely 
fails  if  carefully  followed.  The  etiology  of  foreign  bodies  is  extensive. 
Needles,  especially  portions  of  the  same,  wood,  metal,  and  splinters  of 
glass  form  the  largest  contingent.  The  frequent  "wandering"  due  to 
the  manifold  movements  of  the  hand  and  the  contrast  between  the 
cicatrix  left  behind  at  the  site  of  entrance  and  the  size  of  the  foreign 
body  are  often  surprising. 

In  treating  small  wounds  of  the  hand  and  fingers,  local  anaesthesia 
has  proved  of  immense  value.  For  wounds  of  the  fingers  the  author 
uses  Oberst's  method  exclusively  with  a  simple  4  per  cent,  cocaine 
solution.  Schleieh's  injection  method  is  valuable  in  operations  on  the 
hand  and  wrist;  also  circular  anaesthesia  as  recommended  by  Manz, 
Berndt,  and  Holscher. 

Complicated  Injuries. — The  most  complicated  injuries  of  the  hand 
occur  among  the  operators  of  machinery  in  the  great  industries.  Sudden 
contusion  is  usually  combined  with  the  effects  of  traction  and  tearing. 
The  hand  is  caught  between  toothed  rollers  or  between  driving-wheels  or 
cog-wheels;  is  crushed  or  frayed;  or  there  is  extensive  evulsion  of  tendons 
and  muscles;  or  the  structures  may  be  sawed  smoothly  through  by  a 
circular  saw,  etc.  The  multiplicity  of  wounds  of  the  soft  parts,  tendons, 
joints,  or  bones,  is  often  such  that  the  peculiar  character  of  the  case 
may  make  it  difficult  on  first  inspection  to  form  an  opinion  as  to  the 
prognosis.  It  is  well  before  anaesthetizing  the  patient  to  obtain  permis- 
sion to  do  any  curtailing  operation  that  may  be  necessary. 

It  is  these  severe  complicated  wounds  of  the  hand  that  represent  an 
extremely  profitable  domain  of  conservative  surgery.  The  superficial 
position  and  easy  accessibility,  even  of  the  bones,  reward  one  greatly 
for  proceeding  carefully.  Guided  by  the  experience  that  it  is  impossible 
at  times  to  determine  how  far  contusion  will  be  followed  by  necrosis, 
the  surgeon  will  do  better,  when  uncertain,  to  let  nature  determine  the 
separation  of  living  tissue  from  the  dead:  the  author  saves  everything 
that  can  be  saved,  and  never  cuts  away  anything  merely  for  appear- 
ance' sake.  In  general  it  is  much  better  to  leave  too  much  than  too 
little. 

Not  infrequently  the  first  dressing  may  be  left  on  six,  eight,  or  ten 
days,  and  at  the  end  of  that  time  one  will  often  have  the  satisfaction 
of  finding  a  clean  wound.  The  drains  leading  down  to  the  bone,  joint, 
or  tendon  suture  may  require  changing  on  the  third  day,  and  need  not 
be  replaced  if  the  wound  is  clean.  If  there  is  fever  or  severe  pain  in  the 
wound,  the  dressing  should  be  changed  earlier.  The  appearance  of  in- 
fection and  corresponding  inflammatory  changes  demand  the  applica- 
tion of  all  the  measures  described  under  acute  infections;  loosening  the 
sutures  and  preventing  retention  by  appropriate  drainage.   Formerly,  and 


WOUNDS  OF  THE  HAND  AND  FINGERS.  >s\l 

in  many  clinics,  continuous  irrigation  or  the  continuous  hand-bath  were 
used  extensively  for  beginning  infection.  Their  value  is  incontestable, 
but  at  the  present  time  they  are  generally  abandoned  and  their  equiva- 
lent found  in  wet  dressings.  The  bath  is  indicated,  however,  if  the 
infection  advances  without  recognizable  demarcation  or  abscess  forma- 
tion. If  the  treatment  has  not  been  such  as  was  described  for  the 
"toilet"  of  the  wound  in  recent  injuries,  but  rather  has  gone  too  far  in 
"leaving  the  cleansing  of  the  wound  to  nature,"  or,  what  is  a  greater 
mistake,  the  wound  has  been  closed  tightly  where  there  was  a  possibility 
of  infection,  so  that  the  glowing  coals  are  deposited  in  the  depths,  severe 
infection  is  liable  to  follow. 

The  author  therefore  summarizes  the  therapeutic  Facit  of  these  com- 
plicated wounds  of  the  hand  in  the  words:  First,  to  determine  the 
anatomy  of  the  wound,  tendons,  joints,  nerves,  and,  under  all  circum- 
stances, the  vessels;  then  to  proceed  carefully  to  conserve  the  individual 
parts  and  thereby  the  function;  and  finally  to  leave  the  wound  open  to 
the  proper  extent  on  account  of  the  danger  of  infection.  By  strictly 
observing  these  principles  one  will  not  only  be  agreeably  surprised  in 
the  treatment  of  wounds  of  the  hand,  but  confer  many  a  blessing  upon 
the  welfare  of  the  patient  as  well. 

Serious  Results  of  Wounds  and  the  Possibility  of  Their  Prevention. 

This  subject  has  acquired  an  unusual  practical  significance  in  conse- 
quence of  accident  legislation.  It  deals  with  the  important  question  of  the 
attending  surgeon's  statement  as  to  the  prognosis  of  recent  injuries  and 
the  question  of  estimating  in  advance  the  loss  in  earning-efficiency  to  be 
expected.  It  exposes  the  surgeon  to  manifold  subsequent  criticism  in 
the  discussion  of  what  has  been  done  and  might  have  been  done.  Finally, 
it  arms  the  patient,  under  circumstances,  with  a  just  grievance  as  well 
as  giving  occasion  for  conscious  or  unconscious  exaggeration  of  the 
disability  produced  by  the  injury,  and,  by  reason  of  the  space  taken 
up  by  wounds  of  the  hand  in  the  entire  question  of  accidents,  its  precise 
and  fair  judgment  becomes  a  social  factor  of  the  greatest  importance. 
The  author  will  take  pains  to  place  the  purely  surgically  technical  in 
the  foreground,  still  he  would  be  ignoring  the  practical  character  of  the 
task  before  him  if  in  the  following  lines  he  did  not  allow  the  aid  in  the 
direction  of  the  above-mentioned  judicial  considerations  to  be  recog- 
nizable. 

Changes  in  the  Skin. — Among  the  changes  in  the  skin  following 
injuries,  trophic  and  circulatory  disturbances  are  important.  The 
condition  of  the  finger  which  Ledderhose  terms  "Glanzhaut"  has 
been  seen  following  protracted  immobilization,  the  application  of  con- 
stricting dressings,  or  as  the  result  of  flaps  too  short  for  the  stump. 
Glossy  skin  is  characterized  by  a  peculiar  smoothness,  glossiness,  cold- 
ness, and  purple  hue  of  the  skin;  the  finger  is  large  and  swollen,  or  the 
skin  is  lean  and  tense  like  parchment;  in  fact,  it  reminds  one  of  the  sclero- 
dactylia of  scleroderma,  or  the  "glossy  skin"  referred  tc  contusion  of 


318  INJURIES  OF  THE  WRIST  AND  HAND. 

the  nerve  and  described  by  Paget.  The  condition  may  be  hypertrophic 
or  atrophic.  The  former  represents  to  a  certain  extent  the  first  stage, 
the  latter  the  second  stage  in  the  formation  of  glossy  finger.  The  con- 
dition may  persist  through  life. 

Symptoms. — The  symptoms  are  most  pronounced  toward  the  tip  of 
the  finger.  On  incising  (as,  for  example,  in  reamputation)  the  skin 
shows  a  striking  absence  of  arterial  bleeding.  Microscopically  the 
cutaneous  arteries  show  changes  and  growth  in  the  iiitima,  the  subcu- 
taneous fat  is  absent  and  replaced  by  connective  tissue.  With  this  con- 
dition, even  moderate  cooling  of  the  skin  produces  marked  circulatory 
changes  due  to  the  spastic  contraction  of  the  vessels;  cyanosis,  distinct 
feeling  of  coldness,  and  irritation  of  the  nerve  follow.  The  nervous  dis- 
turbances  lead  more  and  more  to  the  picture  of  a  local  neurasthenia  or 
hysteria,  or  gradually  reveal  a  general  traumatic  neurasthenia.  Glossy 
finger  may  thus  be  a  very  serious  restdt  of  injury. 

The  condition  can  disappear  partially  or  completely  in  a  varying 
length  of  time,  even  within  a  few  months.  The  nervous  changes,  hyper- 
esthesia and  its  reaction  upon  the  function,  once  established  may  persist 
for  a  long  time,  even  in  patients  in  whom  there  can  be  no  question  of 
wilful  exaggeration  of  the  trouble.  There  are  even  cases  in  which 
reamputation  is  the  only  means  of  bringing  about  recovery. 

Treatment. — The  treatment  is  accordingly  extremely  important.  The 
author  agrees  fullv  with  Ledderhose  in  regarding  faulty,  overconserva- 
tive  technic  in  the  amputation  as  the  chief  cause  of  the  condition.  The 
main  things  to  be  avoided  in  the  after-treatment  of  wounds  of  the  fingers 
are  cicatricial  contraction  and  adhesion  of  scant  flaps  of  the  soft  parts 
to  the  bone,  protracted  immobilization  in  splints,  and  the  compression 
of  overtight  bandages. 

Post-traumatic  Neuritis  of  the  Hand  and  Fingers.— In  addition  to 
the  changes  in  the  vessels  and  adipose  tissue  causing  glossy  finger,  the 
wandering  neuritis  following  wounds  of  the  hand  and  fingers  is  interest- 
ing. External  violence  is  an  important  cause  in  diseases  of  the  peripheral 
nerves;  the  disease  is  inclined  to  follow  the  injury  immediately  in  as  far 
as  the  process  of  degeneration  advances  toward  the  periphery.  The 
centripetal  disturbances  in  the  nerve  have  also  been  investigated,  Krehl 
particularly  having  won  the  distinction  of  having  carefully  studied  and 
published  their  symptomatology.  Progressive  neuritis  follows  particu- 
larly the  injuries  accompanied  by  inflammatory  changes.  The  char- 
acteristic and  practically  important  point  in  the  disease  lies  in  the 
fact  that  a  "process  spreading  atypically  produces  the  symptoms  of  a 
disease,  whose  course  is  entirely  incalculable  from  the  outset  and  is 
usually  extremely  chronic."  The  nervous  symptoms  sometimes  appear 
rather  late:  if  there  are  paresthesias  in  the  area  involved,  there  is  dimin- 
ished pressure,  pain,  and  temperature  sense.  Sensory  disturbances  may 
be  absent.  Motor  disturbances  are  constant:  atrophy  of  the  muscles, 
reaction  of  degeneration,  frequently  in  the  small  muscles  of  the  hand, 
the  long  muscles  of  the  forearm  meanwhile  merely  showing  paresis.  The 
treatment  and  prognosis  are  those  of  the  primary  chronic  neuritis. 


WOUNDS  OF  THE  HASH  AND  FINOEES  319 

Cicatricial  Contraction.  The  severity  of  the  contraction  depends 
upon  the  depth  and  extenl  of  the  destruction  and  defect  caused  by  the 
trauma.     The  contractures  following  burns  were  particularly  dreaded 

at  an  earlier  period.  The  contracture  is  due  either  to  shrinkage  of  the 
skin  alone  or  further  to  adhesions  with  the  underlying  parts,  the  tendons 
or  bones;  or  it  is  the  result  of  changes  in  the  tendons,  of  ankylosis 
of  the  joint,  or  of  lesions  in  the  nerves  of  the  antagonistic  muscles.    The 

examination  directed  toward  the  above  disparity  in  the  etiology  will 
always  give  a  clear  idea  of  what  is  possible  by  operation.  (For  details, 
see  section  on  Contractures.)  Very  high-grade  myogenic  contractures 
may  follow  suppurative  myositis  or  the  so-called  ischsemic  paralysis. 

Suppuration  in  the  muscles  of  the  forearm  following  phlegmon  in  the 
fingers  or  hand,  to  be  discussed  later,  may  cause  destruction  of  the  con- 
tractile muscular  fibres,  followed  by  cicatricial  shortening  of  the  muscles. 

Surgeons  are  indebted  to  v.  Volkmann  for  accurate  knowledge  of 
ischemic  paralysis,  the  serious  consequences  of  which  are  seen  especially 
in  the  upper  extremity  from  obstruction  of  the  circulation,  particularly  by 
tight  dressings.  In  a  few  hours  the  patient  complains  of  severe  pain, 
the  parts  not  included  in  the  dressing  being  swollen,  the  fingers  forced 
into  a  flexed  position.  If  the  dressing  is  removed,  the  tense  infiltration 
of  the  muscles  may  disappear  without  damage  and  the  momentary  dis- 
ability rapidly  yield  to  movements.  If  the  circulatory  disturbance  con- 
tinues and  the  dressing  remains  twenty-eight  or  forty-eight  hours,  in 
spite  of  the  patient's  vehement  expression  of  pain,  destruction  of  the 
contractile  substance  of  the  muscles  and  nuclear  degeneration  follow; 
at  the  same  time  there  is  an  enormous  infiltration  of  leucocytes.  These 
changes  do  not  involve  the  muscle  uniformly,  but  in  all  places  where 
they  have  been  pronounced,  severe  muscular  atrophy  follows  with  con- 
tractures of  the  hand  and  fingers.  If  the  circulatory  disturbance  has 
not  existed  too  long,  the  usefulness  of  the  paralyzed  muscle  may  be 
almost  completely  restored  by  movements,  massage,  and  electricity,  if 
persevered  in;  in  the  muscles  greatly  involved,  the  shortening  and 
contracture  persists. 

The  Joints. — Changes  in  the  ligaments,  thickening  and  shrinkage 
following  exudates,  adhesions,  and  circulatory  disturbances  of  various 
kinds,  often  prevent  the  use  of  the  joint  for  a  long  time.  In  the  case 
of  wounds  of  the  hand  and  fingers  it  should  therefore  be  made  a  rule  to 
insure  the  freest  possible  play  of  the  joint  by  omitting  it  in  the  dressing, 
and  if  there  is  inflammatory  or  traumatic  congestion,  to  begin  massage 
and  motion  early.  If  it  must  be  included  in  the  dressing  in  a  splint, 
active  or  passive  motion  should  be  carried  out  at  every  change  of  the 
latter. 

The  degenerative  changes  in  the  joint  itself  are  serious;  they  may  be 
in  the  form  of  loosening  of  the  structures  of  the  joint  after  traumatic 
effusion,  or  long-standing  inflammatory  exudation  in  or  about  the  joint; 
or  immobilization  or  contracture  may  have  kept  parts  of  the  surfaces  of 
the  cartilages  out  of  contact  for  a  long  time.  Actual  deforming  processes 
thus  ensue  in  the  articular  surfaces.     The  disused  cartilage  atrophies 


320  INJURIES  OF  THE   WRIST  AXD  HAND. 

partially  and  is  replaced  by  connective  tissue.  Whereas  the  first-men- 
tioned changes  cao  usually  he  controlled  by  careful  treatment,  the  latter 
naturally  presents  greater  difficulty  and  may  cause  lasting  functional 
loss.  It  is  therefore  advisable  in  every  case  of  protracted  immobilization 
to  insure  the  greatest  possible  range  of  motion  for  the  joint. 

Post-traumatic  Ossifying  Periostitis.— The  significance  of  this  lesion 
for  the  function  of  the  tendons  and  the  joint  should  not  be  underesti- 
mated, yet  the  traumatic  factor  is  not  infrequently  overlooked  in  the 
history.  Following  a  blow  from  a  hammer  or  a  contusion  of  any  sort, 
or  a  severe  strain,  slight  sensitiveness  persists  in  the  bone,  perhaps 
localized  near  the  sprained  joint,  but  not  infrequently  extending  over  the 
entire  metacarpal  or  phalanx.  At  this  stage  the  patient  often  gives  in- 
definite information:  slight  functional  impairment  of  flexion  and  exten- 
sion, easily  regarded  as  exaggeration  or  simulation,  ought  to  indicate 
the  necessity  of  a  careful  comparative  examination.  Likewise  the  .r-ray 
does  not  show  any  alteration  in  the  thickness  of  the  bone.  Later,  the 
thickening  of  the  affected  portion,  or  the  circular  thickening  of  the 
entire  bone,  becomes  more  and  more  plain,  and  in  a  few  weeks  the 
product  of  the  periostitic  ossification  is  evident.  The  otherwise  healthy 
appearance  of  the  patient,  the  occurrence  of  the  affection  in  middle  life, 
and  the  exclusion  of  specific  disease  in  the  history,  soon  establish  the 
diagnosis.  Active  and  passive  motion,  massage,  and  baths  are  to  be 
prescribed;  immobilization  would  be  an  error.  Sudeck  has  called  atten- 
tion to  a  "reflex"  atrophy  of  the  bone,  following  aseptic  inflammations, 
and  recognizable  with  the  aj-ray.    'See  Chronic  Affections  of  the  Bones.) 


CHAPTER   XX. 

DISEASES  OF  THE  WRIST  AND  HAND. 
ACUTE  INFLAMMATORY  PROCESSES  IN  THE  HAND  AND  FINGERS. 

Acute  Inflammatory  and  Phlegmonous  Processes  Starting  as 

Panaritia.    Deep  Phlegmon  of  the  Palm.    Phlegmon 

of  the  Forearm. 

The  acute  inflammations  of  the  soft  parts  of  the  hand  are  so  much 
more  important  than  those  of  the  foot  with  reference  to  temporary  or 
permanent  limitation  of  the  usefulness,  and  thereby  usually  the  earning- 
efficiency,  of  the  hand,  that  the  practical  demands  are  well  met  by  not 
making  the  description  too  short. 

In  the  following  the  author  will  consider  together  all  the  inflammatory 
processes  classified  as  "panaritial."  One  may  differ  in  his  opinion  as 
to  whether  this  corresponds  to  the  present  condition  of  our  knowledge. 
Nevertheless  it  takes  well  into  account  the  practical  and  didactic  needs. 
The  anatomical  differences,  prognostic-ally  so  important,  and  the  corre- 
sponding therapeutic  indications  developing  directly  from  a  picture  of 
infection  that  is  clinically  often  apparently  very  uniform,  appear  to  the 
author  more  profitable  than  any  a  priori  anatomical  definition.  This 
analysis  appears  to  him  all  the  more  urgent  since  even  at  the  present 
time  Konig's  words  still  apply,  namely,  that  "there  are  hardly  any  of 
the  diseases  of  daily  occurrence  which,  by  reason  of  neglect,  so  fre- 
quently produce  serious  result  for  the  patients,  and  in  reference  to  which 
so  many  therapeutic  transgressions  occur,  as  panaritia."  How  much 
can  be  preserved  by  carefulness  and  skill,  how  much  is  sacrificed  with 
reference  to  work  and  existence  by  neglect! 

Every  panaritium  is  an  expression  of  traumatic  inflammation,  whether 
the  surgeon  is  able  to  demonstrate  grossly  the  trauma  and  the  consequent 
lesion  in  the  tissues  or  not.  A  wound  in  the  skin,  often  microscopical, 
serves  as  the  portal  of  invasion  for  the  exciters  of  inflammation.  Today 
surgeons  no  longer  discuss  the  question  of  specific  injuries.  Koch's 
culture  experiments  showed  that  in  every  case  one  or  more  of  the  varieties 
which  are  designated  inexactly  as  pyogenic  bacteria,  were  found  in  the 
inflammatory  exudate:  streptococci,  staphylococci;  exceptionally  bacilli, 
proteus,  coli  communis.  Very  frequently  the  patients  remember  a  small 
puncture-wound  or  laceration  received  within  a  few  days,  or  the  traces  of 
such  are  found.  Often  occupational  injuries  are  responsible,  as  in  the 
case  of  carpenters,  locksmiths,  cooks,  also  surgeons;  anatomists  and 
surgeons  constitute  a  fair  contingent.  Occasionally,  on  incising,  a  small 
Vol.  III.— 21  (  321  ) 


322  DISEASES  OF  THE  WRIST  AND  HAND. 

foreign  body  is  found  in  the  pus:  splinters  of  metal  or  wood,  pieces  of 
fish-bone,  particles  of  bone.  The  disease  is  common  in  youth  and  middle 
age.  The  right  hand  is  more  frequently  affected,  in  proportion  to  its 
greater  use. 

Cutaneous  Panaritium. — The  clinical  aspect  of  cutaneous  panaritium 
is  determined .  by  the  anatomical  peculiarities  of  the  skin  of  the  hand 
and  fingers.  Whereas  elsewhere  on  the  upper  extremity  the  subcutaneous 
connective-tissue  fibres  run  almost  parallel  to  the  long  axis  and  join  skin 
and  fascia  at  a  sharp  angle — as  applies  also  in  general  to  the  back  of  the 
fingers — the  connective  tissue  on  the  flexor  surface  is  thick  and  tense, 
the  fibres  running  in  a  short  course  almost  perpendicularly  inward  from 
the  papillary  bodies.  (Hiiter.)  The  mobility  of  the  volar  skin  upon  its 
substratum  is  therefore  very  limited,  so  that  it  yields  only  slightly  from 
within  outward  (as  in  exudation).  As  the  connective-tissue  spaces  permit 
of  only  slight  lateral  distention,  high  intracutaneous  pressure  is  thus 
rapidly  established.  From  this  it  can  be  understood  why  spontaneous 
perforation  takes  place  at  the  sides  of  the  fingers,  where  the  skin  is  thinner 
and  more  movable;  further,  why  this  localized  increased  pressure  affects 
the  adjacent  structures — tendon-sheaths,  periosteum,  and  joint — at  an 
early  period.  The  first  law  of  treatment  is  immediately  deducible: 
incision  as  early  as  possible. 

Therefore,  although  cutaneous  panaritium  insures  clinically  the  prog- 
nostic advantage  of  local  limitation  and  slow  advancement,  this  mechan- 
ical limitation  has  the  evil  effect  of  producing  very  severe  pain,  necrosis 
of  the  tissues  from  the  marked  impairment  of  the  circulation  due  to  the 
increased  pressure,  and  relatively  high  fever.  The  panaritial  process  in 
many  respects  resembles  furuncular  inflammation,  which  latter  at  the 
outset  meets  with  equally  firm  opposition.  Necrosis  is  rarely  absent  in 
panaritial  inflammation,  as  mentioned. 

The  effects  upon  the  circulation  in  the  unyielding  volar  tissues,  in 
addition  to  favoring  necrosis,  is  manifested  by  a  second  symptom  of  prac- 
tical importance:  the  early  appearance  of  redness  and  swelling  on  the 
dorsum,  where,  as  has  been  seen,  the  connective  tissue  is  much  more 
yielding  and  distensible.  It  is  always  surprising  to  the  beginner,  when 
the  oedema  is  greatest  on  the  dorsum,  to  finally  discover  the  source  of 
infection  and  chief  focus  of  inflammation  on  the  flexor  side;  and  this  is 
where  it  usually  lies.  Incisions  at  wrong  spots  are  often  avenged  by  the 
increasing  opposition  of  the  patient  against  further  possibly  futile 
attempts,  with  the  result  that  a  timely  incision  at  the  proper  place  is 
omitted.  This  dorsal  swelling  can  lead  to  greater  error  in  panaritium 
of  the  palm  than  in  that  of  the  finger.  If  the  inflammation  has  advanced 
beneath  the  palmar  aponeurosis — which  always  happens  if  the  process 
spreads — the  dorsal  swelling  is  more  marked  than  the  symptoms  of 
inflammation  in  the  palm;  for  the  veins  emptying  into  the  large  branches 
of  the  palmar  arch  and  passing  through  the  interosseous  spaces  from 
the  dorsum  to  the  palm,  are  then  under  increasing  pressure.  At  an 
early  period,  therefore,  marked  cyanotic  oedema  is  found  on  the  dorsum, 
whereas  inflammation  beneath  the  thick  callus  of  the  palm  is  hardly 


A  CUTE  IXFLAMMATOR  Y  PROt  ESSES  IX  HAND  AM)  FINGERS.    323 

suspected.  The  primary  focus  of  infection  in  the  palm  cannot  be  over- 
looked if  the  tenderness  is  tested  carefully.  1  >rainage  of  the  tense  exudate 
1S  assured  by  a  wide  incision.  It  is  natural  that  the  clinical  symptoms 
of  cutaneous  panaritium  should  not  he  confined  to  a  typical  region:  the 
site  of  inflammation  may  he  in  the  cushion  of  the  finger-tip  or  at  any 
point  on  the  flexor  surfaces,  although  it  is  usually  in  the  palm. 

Subungual  and  Parungual  Panaritium.— These  forms  are  frequently 
due  to  slight  injuries  of  the  nail-fold  and  of  the  nail  itself,  such  as  the 
penetration  of  small  foreign  bodies  into,  or  small  penetrating  puncture 
wounds  of,  the  matrix,  or  similar  injuries  usually  regarded  by  the  patient 
as  insignificant.  The  tenderness  is  particularly  great  if  the  affection 
develops  beneath  the  nail,  whereas  as  soon  as  it  reaches  the  dorsum  of 
the  finger  it  diminishes  rapidly  for  the  above  anatomical  reasons,  so  that 
considerable  pus  may  collect  without  causing  much  pain. 

The  nail  is  frequently  destroyed;  its  extraction  is  followed  by  diminu- 
tion of  the  pain  and  favors  recovery.  The  dressing-forceps  or  Trendelen- 
burg's extraction-forceps  (Fig.  209)  are  useful. 

Fig.  209. 


Trendelenburg's  nail-extractor. 

Panaritium  of  the  Tendon-sheaths. — This  affection,  which  deserves 
especial  mention,  is  discussed  here  purely  on  practical  grounds  and  in 
order  to  avoid  otherwise  necessary  repetition.  A  glance  at  the  course 
of  the  tendon-sheaths  in  the  palm  and  dorsum  (Fig.  173)  will  show  how 
far  inflammatory  processes  can  extend  immediately  or  later.  The  most 
important  criterion  of  the  affection  is  its  rapid  advancement  with  pain 
and  impaired  motion  of  the  corresponding  tendon. 

It  is  important  practically  that  the  flexor  tendon-sheaths  of  the  second 
and  fourth  fingers  very  rarely  connect  directly  with  the  common  tendon- 
sheath  of  the  wrist.  The  illustration  saves  further  discussion  of  the 
anatomy;  it  teaches  that  from  the  flexor  tendon-sheath  of  the  thumb 
the  process  can  spread  rapidly  up  to  and  beneath  the  transverse  carpal 
ligament  and  involve  the  common  tendon-sheath  of  the  remaining 
flexors  as  the  result  of  the  high  pressure  of  the  exudate;  it  can  even 
invade  the  tendon-sheath  of  the  little  finger,  in  which  case  it  may  advance 
directly  upward  upon  the  synovial  sheath  of  the  palm  beneath  the  carpal 
ligament.  The  sheaths  of  the  second  and  fourth  fingers,  ending  almost 
always  at  the  level  of  the  heads  of  the  metacarpals,  usually  check  the 
infection  at  this  point.  Failure  to  recognize  and  expose  the  exudate 
in  the  tendon-sheaths  of  the  latter  fingers  may  mean  infection  of  the 
palm;  the  common  tendon-sheath,  however,  is  thereby  not  endangered 
to  the  same  extent.  On  the  dorsum  the  tendon-sheaths  are  not  so 
extensive,  so  that  the  inflammation  does  not  spread  so  rapidly. 


324  DISEASES  OF  THE  WRIST  AND  HAND. 

In  panaritium  of  the  tendon-sheath  the  swelling  extends  along  the 
entire  finger,  the  interphalangeal  folds  are  flattened  out  or  effaced 
and  the  swelling  usually  ends  distally  at  the  base  or  the  middle  of  the 
third  phalanx,  whereas  the  tip  of  the  finger  may  be  relatively  free;  the 
swelling  at  the  sides  and  on  the  dorsum  is  less  distinct.  In  cutaneous 
panaritium,  in  contrast,  there  is  a  medial  longitudinal  swelling  on  the 
volar  surface.  All  these  symptoms  are  marked  in  recent  cases  of  pure 
panaritia  of  the  tendon-sheaths.  They  are  even  more  marked  in  acute 
gonorrhneal  and  chronic  tuberculous  inflammation.  The  term  pure  pana- 
ritium is  used  because  the  adjacent  tissues — skin,  periosteum,  and  especi- 
ally the  joints  with  which  the  tendon-sheaths  occasionally  communi- 
cate, are  frequently  involved  if  the  affection  is  protracted. 

Osseous  Panaritium. — This  primary  inflammatory  process  of  the 
periosteum  is  included  here  for  the  sake  of  clearness.  It  is  more  com- 
monly the  result  of  small  infected  puncture-wounds,  and,  like  all  affec- 
tions of  the  bone  and  periosteum,  is  characterized  from  the  outset  by 
intense  pain;  sleepless  nights  are  the  frequent  result,  as  in  the  sub- 
ungual form.  Naturally  the  process  should  give  the  maximum  of 
inflammatory  symptoms  in  the  limited  area  of  a  phalanx,  and  generally 
this  is  clearly  demonstrated.  The  swelling,  as  in  diseases  of  the  peri- 
osteum and  bone,  is  generally  cylindrical,  but  may  be  more  pronounced 
on  the  dorsum,  where  the  skin  is  more  yielding.  Whereas  in  the  cuta- 
neous form  spontaneous  perforation  of  the  pus  depends  upon  the  site  of 
infection — and  in  the  tenosynovial  form  the  perforation  occurs  preferably 
at  the  ends  of  the  tendon-sheaths,  usually  the  distal  end — in  the  periosteal 
form  there  are  frequently  numerous  fistulas,  mostly  at  the  sides  of  the. 
finger.  If  of  longer  duration,  the  fistula?  show  characteristic  puffed, 
rosette-like  granulations.  If  the  diagnosis  is  still  uncertain,  the  probe 
will  demonstrate  a  sequestrum  of  the  larger  part  or  the  whole  of  the 
phalanx. 

Articular  Panaritium. — In  tins  form,  which  occurs  either  primarily 
or  secondarily,  there  is  usually  intense  pain,  as  in  all  acute  infections 
of  the  joints.  As  the  skin  over  the  joint  on  the  dorsum  is  rarely  more 
than  1.5  to  2  mm.  thick,  superficial  lesions  will  be  close  to  or  penetrate 
the  joint.  The  acute  inflammatory  exudate  distends  the  skin  on  the 
dorsum  into  a  hemispherical  sac;  the  transverse  skin  folds  are  obliterated 
and  the  joint  becomes  semiflexed,  the  position  giving  the  greatest  space 
to  the  exudate.  If  left  to  itself,  the  exudate  soon  produces  necrosis  of 
the  cartilage  and  rapidly  perforates  to  the  surface;  if  less  acute,  namely, 
in  the  serous  form,  it  is  followed  by  ankylosis,  more  or  less  pronounced 
crepitus,  and  pain  on  motion.  Although  of  rare  occurrence,  the  author 
knows  from  numerous  careful  observations  that  a  pure  serous  exudate 
is  possible  in  staphylococcus  infection,  the  inflammation  stopping  at  this 
stage  with  gradual  death  of  the  bacteria  and  the  preservation  of  the 
joint-function. 

The  fever  accompanying  panaritial  inflammation  varies,  and  is  some- 
times ushered  in  by  one  or  more  chills;  this  applies  to  all  forms  of 
panaritia,  but  particularly  to  those  of  the  bones,  joints,  and  tendon- 


ACUTE  INFLAMMATORY  PROCESSES  IN  HAND  AND  FINGERS.    325 

sheaths.  The  high  pressure  under  which  the  inflammatory  exudation 
exists,  as  has  been  seen  in  the  cutaneous  variety,  explains  the  frequenl 
discrepancy  between  the  height  of  the  fever  and  the  size  of  the  focus  in 
volar  panaritia.  Formerly  the  degree  of  fever  was  ascribed  entirely  to 
these  physical  peculiarities,  but  it  is  known  now  that  it  depends  greatly 
upon  the  kind  of  bacteria  in  the  tissues,  the  rapidity  of  their  growth, 
and  the  virulence  of  their  toxins. 

Course. — The  duration  of  the  various  infections,  independent  of  the 
anatomical  differences  of  the  skin,  tendon-sheath,  hone,  and  joint, 
depends  upon  the  susceptibility  and  power  of  resistance  of  the  individual 
and  the  virulence  and  toxicity  of  the  bacteria.  In  the  cutaneous  form 
pronounced  necrosis  is  seen  following  within  a  few  hours  or  days,  with 
marked  constitutional  symptoms,  and,  if  not  cheeked  at  an  early  period 
by  incision,  accompanied  under  circumstances  by  the  severe  general 
infection.  In  other  cases,  days  or  one  or  two  weeks  pass;  the  use  of 
the  hand  is  little  impaired;  the  patient  employs  ordinary  remedies  and 
incision  shows  a  limited  focus;  or,  it  may  perforate  spontaneously  and 
recovery  follow  the  sloughing  of  the  necrosed  tissue.  In  the  tendon- 
sheaths  the  process  is  rather  rapid  (foudroyant );  the  exudate  becomes 
purulent  within  a  few  days;  the  feeble  circulation  in  the  tendons  is 
checked  and  necrosis  is  the  inevitable  result.  Non-surgical,  namely, 
expectant,  treatment  of  purulent  tenosynovitis  is  hazardous  for  the 
later  use  of  the  hand  and  fingers,  and,  under  circumstances,  even  for 
life  itself.  In  from  three  to  six  weeks  the  portion  of  the  tendon  lying 
necrotic  in  the  purulent  exudate  is  cast  off  as  a  vermiform  slough 
through  a  fistulous  opening  forming  spontaneously  or  after  incision. 
The  process  may  stop  here;  contraction  follows,  and  nothing  is  able 
to  replace  the  loss  of  the  tendon.  The  uselessness  of  the  finger  is 
often  an  indication  for  later  amputation.  If  the  process  advances 
upward,  however,  the  symptoms  of  phlegmon  of  the  palm  follow, 
and  there  may  be  septic  erosion  of  the  vessels;  by  timely  interference 
it  may  be  checked  at  this  level.  Even  then  it  is  usually  months 
before  the  use  of  the  hand  is  regained.  If  the  suppuration  advances 
upward  beneath  the  carpal  ligament  and  beyond  the  upper  end  of  the 
tendon-sheaths,  the  symptoms  may  be  marked  or  the  process  may  ad- 
vance insidiously  (often  signalized  merely  by  further  attacks  of  fever, 
weakening  the  patient)  between  the  tendons  and  muscles  and  cause 
deep  phlegmon  of  the  arm.  To  explore  and  check  the  suppuration 
may  tax  even  the  skill  of  the  experienced.  Suppuration  along  the  inter- 
osseous ligament  may  remain  concealed  beneath  a  tense,  inflammatory 
myositis  of  the  flexor  muscles;  it  may  perforate  toward  the  posterior 
surface,  cause  deep-seated  purulent  lymphangitis  and  septic  thrombo- 
phlebitis, and  for  weeks  threaten  life.  The  limb  may  be  saved  by 
incising  freely  and  dilating  the  openings  with  dressing-forceps;  amputa- 
tion is  sometimes  necessary,  however,  If  the  process  is  checked,  the 
result  is  muscular  degeneration,  cicatricial  shrinkage,  contracture, 
and  great  impairment  of  hand  and  arm.  The  course  and  treatment 
extend  over  months  and  the  orthopsedic  after-treatment  often  over  six 


326  DISEASES  OF  THE  WRIST  AND  HAND. 

months  or  longer.    The  earning-efficieney  of  the  laboring-man  is  often 
lost  for  more  than  a  year. 

Treatment. — The  treatment  consists  in  incising  the  primary  focus  as 
early  as  possible.  It  may  be  difficult  to  find  the  focus,  even  in  the  cuta- 
neous form,  but  exploration  is  usually  facilitated  by  carefully  searching 
for  the  point  of  greatest  tenderness.  By  timely  interference  the  surgeon 
is  in  a  position  to  prevent  the  dangers  of  further  absorption  of  the  infec- 
tious material,  and  to  limit  the  focus  of  inflammation.  Even  with  the 
law  nihil  nocere  in  mind  the  author  is  convinced  that  it  is  better  to  incise 
too  soon  or  too  freely  than  to  err  in  the  opposite  direction.  In  cutaneous 
panaritium,  if  the  centre  of  the  inflammation  is  not  yet  denoted  by 
an  ansemic  or  yellowish  color  of  the  skin,  it  is  well  to  determine  the  most 
sensitive  point  with  the  end  of  the  probe  or  similar  object  and  make 
an  incision  \  to  1  inch  long.  After  incising,  a  wet  dressing  of  boro- 
salicylic  acid  or  aluminum  acetate,  lead  subacetate,  or  salt  solution,  gives 
the  greatest  comfort.  The  condemnation  of  wet  dressings  as  being  a 
"damp  chamber"  encouraging  the  development  of  bacteria  and  thereby 
the  infection  should  be  withdrawn.  Their  application  depends  not  upon 
their  imputed  gross  mechanical  effect  on  the  bacteria,  but  upon  their 
physiological  action  on  the  vessels  of  the  tissues  covered,  as  is  easily 
studied  experimentally.  The  wet  dressing  is  indicated  until  the  inflam- 
matory process  becomes  limited,  after  which,  with  regard  to  the  skin, 
it  is  better  to  replace  it  by  an  ointment  or  dry  dressing.  If  the  skin  is 
very  sensitive,  a  dressing  of  salicylic  acid,  alone  or  with  a  slight  admixture 
of  zinc  sulphate,  is  advisable  from  the  outset;  sterilized  or  boiled  water 
soon  causes  eczema.  To  "plug"  the  wound  with  agglutinating  powder 
does  not  correspond  to  the  ideal  physical  conditions  for  drainage. 

Salzwedel  warmly  recommends  an  alcohol  compress  applied  as  follows: 
"An  eight-fold  strip  of  muslin,  fat-free,  is  saturated  with  alcohol,  applied 
to  the  skin,  and  covered  with  a  loose  dry  layer  of  cotton  1  to  \\  inches 
thick;  over  this  is  spread  a  covering  of  some  perforated,  impervious 
material,  and  the  whole  bound  with  thin  muslin  or  cambric."  Ninety- 
five  per  cent,  alcohol  is  the  best;  "weaker  should  only  be  used  in  an 
emergency."  Under  the  rest  of  the  bandage  the  skin  should  be  covered 
with  a  loose  layer  of  dry,  iodoform,  or  plain  gauze.  The  dressing  is 
usually  left  on  twenty-four  hours.  A.  Schmitt,  Korsch,  Graser,  and 
others  recommend  this  method. 

Immobilization  of  the  finger,  the  hand,  or  if  necessary  the  entire  arm, 
is  in  accord  with  the  law  of  rest  in  the  treatment  of  all  inflammatory 
processes.  If  the  patient  is  sensitive  or  if  the  infection  is  ushered  in  or 
accompanied  by  high  temperature,  rest  and  suspension  of  the  arm  should 
be  prescribed.  An  ice-bag  at  the  elbow,  or  better  in  the  axilla,  com- 
pletes the  desired  antiphlogistic  treatment.  The  author  almost  always 
incises  under  Oberst's  local  anaesthesia.  For  panaritium  of  the  palm 
simple  cocaine  anaesthesia  or  Schleich's  injection  method  is  valuable, 
but  the  author  makes  it  a  rule  never  to  use  more  than  §  grain  of 
cocaine  at  once,  employing  a  4  per  cent,  solution  and  waiting  a  short 
time  for  the  effect. 


ACUTE  INFLAMMA  TOR  Y  PROCESSES  IN  HAND  AND  FING  EBS.     327 

Frequently  it  is  well  to  employ  general  anaesthesia,  and  after  incising 
the  skin  to  dissect  bluntly  with  the  forceps  to  obtain  a  wide  path  for 
drainage.  A  fair-sized  drainage-tube  is  usually  preferable  to  gauze, 
the  incision  not  being  made  too  small — 1  to  1  \  inches — and  hemorrhage 
being  checked  by  appropriate  retraction  of  the  edges  and  ligation. 
Annoying  secondary  hemorrhage  is  not  infrequent.  In  the  initial  stages 
of  panaritium  expectant  treatment  is  still  much  in  vogue,  the  limb  being 
immobilized,  wet  dressings  or  hot  poultices  being  applied,  and  a  posi- 
tive, purulent  dissolution  awaited.  This  method  seems  to  the  author 
to  be  justified  only  by  accurate  determination  of  the  chief  source  of 
infection  or  by  great  fear  of  the  knife  on  the  part  of  the  patient;  the 
latter  will  have  to  pay  for  his  opposition  with  long-continued  pain, 
great  loss  of  tissue,  protracted  illness,  and  severe  functional  impairment. 
The  great  number  of  other  methods,  inunction,  painting  with  astringent 
substances,  iodine,  ichthyol,  etc.,  have  as  little  justification  for  being 
used  as  the  compression  methods — founded  originally  upon  the  erro- 
neous idea  that  they  limit  the  inflammatory  swelling — have  for  being 
rejected.  Unfortunately  one  not  infrequently  sees  the  misuse  of  carbolic 
dressings  of  varying  strength  at  the  onset  of  the  process  and  the  resulting 
carbolic  gangrene.     (See  section  on  Carbolic  Gangrene.) 

For  the  tenosynovial  variety,  early  incision  is  of  first  importance;  it 
may  mean  the  prevention  of  necrosis;  generally  the  tendons  remain 
adherent  for  some  time.  Occasionally  the  mobility  of  the  tendons  can 
be  restored  later  if  surgeon  and  patient  spare  no  efforts  in  the  after- 
treatment:  massage,  passive  motion,  baths,  finally  electricity  to  the  cor- 
responding muscles,  and  especially  orthopaedic  measures.  A  cicatrix  can 
be  made  yielding  even  after  months;  the  endothelium  covering  the  tendon 
and  its  sheath  possesses  great  regenerative  power.  Naturally,  firm 
fibrous  adhesions  of  long  standing  cannot  be  replaced  by  endothelium, 
so  that  the  orthopaedic  measures  should  follow  immediately.  Cases  of 
obliteration  seen  a  year  or  more  after  the  inflammation  are  hopeless. 

If  the  process  cannot  be  checked  in  the  early  stages,  or  if  the  case  is 
first  seen  after  suppuration  or  necrosis  has  begun,  the  entire  focus  should 
be  opened  by  an  incision  1  to  1+  inches  long.  (See  Fig.  173.)  To  scrape 
out  the  necrotic  tissue  before  demarcation  occurs  is  not  in  accordance 
with  our  present  knowledge  of  infectious  processes;  where  there  is  not 
much  to  save,  but  rather  new  complications  can  be  caused  by  stirring  up 
the  inflammation,  the  author  prefers  to  confine  himself,  at  this  stage,  to 
exposing  and  draining  the  focus,  and  to  await  separation  and  sloughing 
of  the  tissues.  Where  and  when  to  amputate  a  finger  rendered  useless 
by  complete  necrosis  of  the  tendons  depends  upon  the  desire  and  posi- 
tion of  the  patient,  upon  later  expediency,  or  upon  aesthetic  considera- 
tions. Generally,  in  patients  or  classes  dependent  upon  manual  labor 
the  author  amputates  immediately  after  the  symptoms  of  inflammation 
have  subsided  if  there  is  no  prospect  of  recovering  motion.  Although 
the  author  amputates  or  resects  according  to  the  immediate  necessity, 
he  prefers  to  exarticulate  and  to  suture  the  flaps  with  retention  sutures. 
He  avoids  wounding  the  spongiosa  on  account  of  the  possibility  of  re- 


328  DISEASES  OF  THE  WRIST  AXD  HAND. 

newed  infection  that  is  present  for  a  long  time  in  the  previously  infected 
tissues. 

If  the  patient  comes  for  treatment,  however,  with  the  consequences 
of  previous  infection  of  the  tendon-sheaths — stiff  fingers — the  above 
considerations  do  not  apply,  and  the  surgeon  is  concerned  merely  in 
obtaining  the  best  possible  function;  for  example,  if  there  is  stiffness  of 
the  middle  finger,  amputation  of  the  metacarpal  at  the  neck.  Dis- 
criminative operating  has  proved  its  value  in  the  treatment  of  contrac- 
tures of  the  fingers. 

In  the  palm  the  author  distinguished  between  superficial  cutaneous 
processes  and  the  deep  phlegmon  developing  beneath  the  palmar  ap- 
oneurosis. In  the  former,  simple  incision  usually  brings  recovery;  in 
the  latter  case  the  knife,  or  better  the  closed  dressing-forceps,  should  be 
introduced  between  the  fibres  of  the  aponeurosis,  the  blades  opened  and 
then  withdrawn.  Free  exit  is  thus  obtained  for  the  pus.  The  author 
prefers  in  the  severe  forms  of  deep  phlegmon  to  thrust  the  forceps  through 
to  the  posterior  surface  between  the  metacarpals,  to  make  a  counter- 
opening,  and  secure  through  drainage.  It  is  best  to  do  the  operation 
under  anaesthesia.  In  this  way  it  is  often  possible  to  control  suppuration 
existing  under  pressure  beneath  the  aponeurosis.  The  increasing  hemor- 
rhage during  the  operation  need  not  be  feared  if  the  trunk  of  the  palmar 
arch  is  avoided;  if  the  edges  of  the  wound  are  forcibly  retracted,  the 
source  of  the  bleeding  can  usually  be  found.  Spontaneous  secondary 
hemorrhage  from  the  eroded  vessels  in  the  palm  can  be  more  trouble- 
some. As  much  as  the  author  objects  to  applying  the  Esmarch  in 
phlegmonous  processes,  it  is  the  best  means,  in  this  case,  of  obtaining  a 
good  view  of  the  bleeding  area,  as  the  source  of  hemorrhage  can  be 
located  by  its  alternate  application  and  removal.  It  is  in  these  cases  of 
secondary  septic  hemorrhage  that  one  has  the  disagreeable  experience 
of  having  the  clamp  repeatedly  tear  the  friable  wall  of  the  vessel,  fall 
off,  and  occasion  renewed  hemorrhage.  The  author  has  always  been 
able  to  check  the  hemorrhage,  however,  without  ligating  in  continuity, 
in  contrast  to  previous  experience. 

If  the  process  extends  tipward  beneath  the  carpal  ligament  to  the 
subfascial,  intermuscular  spaces  of  the  arm  in  the  manner  described, 
every  newly  suspected  focus  should  be  attacked  with  scalpel  and  forceps 
— avoiding  the  nerves  and  vessels— and  drained  freely,  with  care  that 
the  drains  are  not  so  small  as  to  be  compressed  by  the  tense  tissues. 
If  free  drainage  is  not  obtained  at  the  transverse  ligament,  the  latter 
should  be  divided,  in  view  of  the  danger  to  the  carpal  joints.  (Helferich, 
Konig.)  Phlegmon  in  the  dorsum,  more  rare  and  less  serious,  requires 
the  same  treatment. 

In  the  osseous  form  the  separation  of  the  sequestrum  should  beawaited, 
possibly  an  incision  made  to  relieve  the  pain.  This  separation  occurs 
in  from  two  weeks  to  two  months,  according  to  the  age  of  the  patient, 
the  condition  of  the  circulation  and  of  the  tissues,  and  the  amount  of 
necrosis.  The  sequestrum  is  exposed  by  a  lateral  incision  the  length 
of  the  phalanx — thus  avoiding  the  tendons  and  the  areas  of  touch — 


ACUTE  INFLAMMATORY  PROCESSES  IS  HAND  AND  FINGERS.    ;]29 

and  is  removed  without  difficulty.  The  operation  is  easy  with  Oberst's 
anaesthesia.  Packing  the  small  cavity  causes  it  to  be  rapidly  filled  in 
by  granulation. 

The  joint-affection,  if  seen  early,  recovers  best  by  incising;  later,  after 
the  formation  of  fistulas  and  erosion  of  the  cartilage  with  crepitus  on 
motion,  one  should  cither  encourage  ankylosis  by  immobilizing  and 
keeping  the  wound  open  or  resect  the  head  of  the  proximal  hone,  or 
both  articular  surfaces,  with  Liston's  forceps.  Recovery  is  usually 
rapid  and  uninterrupted.  Sometimes  there  is  fail-  motion  without  pain, 
then  again  ankylosis. 

Acute  and  Subacute  Infections  of  the  Soft  Parts  of  the  Hand  and 
Fingers  (Non-panaritial). 

Furuncle. — Owing  to  the  absence  of  sebaceous  glands  in  the  palm, 
genuine  furuncular  inflammations  occur  only  on  the  dorsum.  They  are 
often  seen  in  harness-makers,  leather-workers,  and  in  those  coming  in 
contact  with  pus  and  purulent  processes — surgeons,  dissecting-room 
orderlies.  They  do  not  differ  essentially  in  any  part  of  their  course 
from  the  other  furuncular  inflammations  except  that  the  lymphadenitis, 
especially  in  the  axilla,  frequently  becomes  preponderant.  The  glands 
running  from  the  axilla  to  the  coracoid  process  under  the  pectorals  are 
not  infrequently  swollen  and  purulent.  The  infections  accompanied  by 
high  fever  are  due  to  streptococci,  whereas  the  milder  forms  are  always 
staphylococcus  infections,  often  the  staphylococcus  albus,  which  is  so 
frequently  found  everywhere  in  the  skin. 

Treatment. — The  treatment  is  on  general  principles.  The  expectant 
treatment — poultices,  dressings  of  balsam  of  Peru,  etc.,  till  the  abscess 
becomes  "ripe"  and  then  incision — still  has  many  advocates.  Others 
incise  early  to  prevent  spreading.  There  is  a  good  deal  to  be  said  on 
both  sides,  in  view  of  the  comparatively  slight  pain  of  dorsal  furuncle 
compared  to  that  of  volar  panaritium,  the  difference  being  attributable  to 
the  looseness  of  the  skin  on  the  dorsum.  If  the  symptoms  are  severe, 
namely,  high  fever  and  impending  lymphangitis,  the  author  incises  and 
drains,  but  in  the  less  acute  forms  he  awaits  the  formation  of  an  abscess, 
applying  wet  dressings  and  immobilizing  upon  a  small  splint.  The 
onset  of  lymphangitis  and  lymphadenitis  demands  complete  rest  and 
the  application  of  ice  in  the  axilla. 

The  Primary  Effects  of  Syphilis.— The  primary  effects  may  be  mani- 
fested for  a  long  while  merely  as  a  harmless  paronychia.  On  the  fingers 
the  author  has  only  seen  it  about  the  nail  and  in  connection  with  small 
fissures  at  the  nail-fold.  The  slow  development,  relatively  slight  pain, 
sluggish  appearance  of  the  partially  necrotic,  punctate  granulations,  and 
the  absence  of  epithelial  growth  along  the  edges  are  the  chief  symptoms. 
In  only  one  of  the  cases  and  at  a  later  period  was  there  induration  corre- 
sponding to  the  induration  which  the  author  is  accustomed  to  see  witli 
the  typical  nodules  of  Hunter.  The  diagnosis  is  supported  further  by 
the  slow  course  of  the  local  inflammation  and  the  very  characteristic 


330         DISEASES  OF  THE  WRIST  AND  HAND. 

form  of  the  associated  lymphangitis.  There  is  marked  infiltration  of 
the  lymphatics  on  the  back  of  the  forearm  and  the  cubital  glands  are 
distinctly  swollen  in  the  third  to  the  fourth  week.  Thick,  hard,  irregular 
cords  run  upward  in  the  bicipital  sulcus  and  at  the  inner  side  of  the 
biceps.  The  glands  are  largest  in  the  axilla  and  under  the  pectoralis. 
The  swelling  has  already  begun  to  recede  when  the  sudden  appearance 
of  the  general  roseola  in  the  sixth  to  the  ninth  week  after  the  infection 
makes  the  hitherto  possibly  doubtful  diagnosis  unavoidable.  The  tem- 
perature, observed  commonly  in  syphilis  at  the  time  of  the  appearance 
of  the  hard  chancre  and  the  constitutional  symptoms,  is  also  met  with 
here  in  the  form  of  irregular  febrile  movements.  Still  the  exacerbations 
stand  in  no  direct  relation  to  the  extent  and  severity  of  the  lymphatic 
infiltration. 

Treatment. — Naturally  the  treatment  does  not  differ  from  that  of  the 
ordinary  infection,  and  an  incision  upon  the  increasing  and  occasionally 
pseudofluctuating  infiltrate  would  not  have  the  desired  effect. 

Erysipelas. —It  may  be  surprising  to  know  that  the  author  has  rarely 
seen  true  erysipelas  in  the  fingers  and  hand.  If  with  Billroth  one  regards 
erysipelas  as  a  superficial  lymphodermatitis,  the  conclusion  is  justifiable 
that  the  relative  infrequency  of  the  disease  depends  upon  the  arrange- 
ment of  the  cutaneous  lymph-spaces  of  the  hand  and  fingers.  Oppor- 
tunities for  infection  are  not  lacking,  yet  the  author  may  say  that  genuine 
erysipelas  is  as  rare  as  panaritium  is  frequent.  The  clinical  course  is 
almost  always  characterized  by  rapid  advance  of  the  erythema  and  high 
temperature. 

Treatment. — The  author  foregoes  every  operative  measure;  provides 
for  rest  and  elevation  of  the  limbs,  and  relaxation  of  the  skin  by  means 
of  wet  compresses  renewed  two  or  three  times  daily  if  possible,  and 
incises  only  in  case  of  pus.  The  diet  should  be  restricted.  This  is  not 
the  place  to  discuss  the  occasional  danger  of  extension  of  the  infection, 
as  in  that  case  the  surgeon  has  to  deal  with  processes  involving  more 
than  the  hand  and  fingers. 

Pseudoerysipelas. — By  pseudoerysipelas,  or  erysipeloid,  is  under- 
stood an  affection  of  rather  frequent  occurrence,  similar  in  its  symptoms 
to  erysipelas,  but  differing  in  its  etiological  and  prognostic  significance. 
In  it  there  is  also  a  superficial  lymphangitis.  The  affection  is  acquired 
almost  without  exception  in  kitchens,  meat-shops,  fish-  and  game-shops, 
etc..  and  is  always  found  to  be  caused  by  slight  wounds  from  fish-bones, 
lobster-shell-,  splinters  of  bone,  etc.,  if  recognized  by  the  patient. 

Symptoms. — The  congestion  is  the  most  prominent  symptom,  develop- 

v  I an-  I  or  insular  slowly  upward  with  deep  cyanosis  or  copper 

coloring  of  the  skin,  and  accompanied  by  more  or  less  intense  pain. 
The  infiltration  is  glistening,  well-defined,  and  projects  in  places  above 
the  level  of  the  skin.  There  are  no  serious  constitutional  symptoms  or 
swelling  of  the  glands  of  the  arm,  an  important  point  in  the  differential 
diagnosis.  For  years  the  author  has  described  this  affection  to  students 
as  a  pronounced  local  toxic  process,  the  cyanotic  congestion  being  the 
result  of  local  paralysis  of  the  vessels.     From  our  present  knowledge  of 


ACUTE  INFLAMMA  TOR  V  PROCESSES  IN  HAND  AND  FINGERS.    331 

the  condition  it  is  easy  to  conceive  thai  ferments,  adherent  to  the  above- 
mentioned  dead  pieces  of  fish  or  flesh,  and  inoculated  into  the  skin  of 
the  finger  through  a  small  wound,  are  carried  into  the  superficial  lymph- 
spaces,   producing  paralysis  of  the   vessels  varying  according  to  the 

amount  and  toxicity  of  the  ferment. 

Prognosis. — The  prognosis  is  always  good,  and  the  patients,  anxious 
on  account  of  " blood-poisoning,"  can  be  convinced  in  two  to  four  days 
of  the  harmlessness  of  the  trouble  by  making  a  small  incision  at  the 
point  where  the  supposed  poison  has  found  it-  strongest  expression  and 
by  immobilizing  the  part.  It  should  he  emphasized  that  operation  is 
not  necessary. 

Lymphangitis  and  Phlebitis.— Lymphangitis,  in  the  strictest  sense, 
has  been  mentioned  repeatedly  in  connection  with  panaritium,  furuncle, 
and  erysipelas.  According  to  the  old  clinical  use  of  the  term,  the  author 
still  understands  merely  the  infection  as  manifested  by  the  classical  red 
streaks  following  the  course  of  the  larger  lymphatics  along  the  extremity. 
It  should  be  borne  in  mind,  however,  that  all  diffuse  diseases  of  the 
superficial  and  deep  tissues,  whether  in  the  trunks  or  the  free  capillary 
network  of  the  lymph  system,  are  in  the  main  lymphangitic.  One's  ap- 
preciation of  the  affection  is  best  aided  by  the  old  well-known  idea  of 
His,  representing  all  the  cellular  tissue  elements  as  swimming  in  a  sea 
of  lymph.  By  far  the  greater  number  of  infections  are  conveyed  by 
the  lymph  in  its  smallest  intercellular  channels  and  streams.  The  red 
streaks  of  this  form  of  lymphangitis  are  not  recognizable  in  the  skin 
of  the  hand  and  fingers  except  on  the  dorsum  and  on  the  volar  surface 
of  the  wrist.  This  subject  therefore  carries  us  beyond  the  region  of 
the  hand;  still  it  should  be  mentioned,  as  the  hand  is  the  most  frequent 
starting-point  of  lymphangitis  of  the  arm. 

It  is  almost  always  a  streptococcus  infection  which  causes  the  lymph- 
angitis, and  usually  follows  small  foreign  body,  puncture-  or  tear- 
wounds,  and  the  like,  or  is  the  result  of  extensive  suppuration.  Con- 
tinued use  of  the  extremity  after  the  injury,  or  after  the  infection  has 
already  been  established,  has  doubtless  much  to  do  with  the  production 
of  the  lymphangitis.  Later  the  infection  is  by  no  means  always  limited 
to  the  lymphatics,  but  infiltrates  the  adjacent  tissues.  After  the  acute 
symptoms  have  subsided  the  author  often  finds  more  or  less  painful 
cord-like  lines  of  infiltration  the  size  of  a  lead-pencil,  especially  on  the 
anterior  surface  of  the  extremity,  which  may  last  for  weeks  or  months. 
The  "dissector's  lymphangitis"  of  the  upper  extremity,  a  cadaver  infec- 
tion (usually  streptococcus*,  is  properly  regarded  with  fear;  it  starts  with 
frequent  chills,  or,  in  contrast,  the  local  process  spreads  steadily  with 
almost  complete  a  pyrexia.  The  lymph-glands  either  suppurate  slowly 
or  painful  swellings  persist  without  recognizable  suppuration.  Renewed 
chills  at  the  end  of  several  weeks  suddenly  signalize  insidious  metastases 
in  the  body,  endocarditis,  pleurisy,  etc.  The  prognosis  of  these  phleg- 
monous processes,  especially  those  of  the  palm,  may  be  made  serious 
by  the  infection  becoming  general  from  a  phlebitis  and  periphlebitis. 


332  DISEASES  OF  THE  WRIST  AND  HAND. 


FEOST-BITES  AND  BURNS. 

In  addition  to  the  general  symptoms  of  frost-bites  and  burns,  which 
will  not  be  discussed  here,  certain  local  symptoms  should  be  mentioned 
on  account  of  the  frequency  with  which  the  fingers  and  the  hand  are 
involved. 

Frost-bite. — In  cases  of  freezing  the  capillaries  dilate  from  the  action 
of  the  cold  and  then  contract  from  the  irritation  of  the  skin ;  then  follow 
changes  in  the  blood,  muscular  rigidity,  necrosis  of  the  contractile  sub- 
stance, and  nuclear  degeneration.  (Kraske,  Volkmann.)  While  the  freez- 
ing lasts  it  is  not  possible  to  determine  the  amount  of  damage.  After  the 
parts  have,  thawed,  according  to  the  degree  of  freezing  there  may  be:  red- 
ness and  swelling  with  temporary  dilatation  of  the  capillaries  (congela- 
tion erythema,  first  degree  of  frost-bite);  or  separation  of  the  epidermis, 
vesicles,  from  the  exudation  caused  by  stasis,  accompanied  by  super- 
ficial loss  of  substance  (second  degree) ;  or  gangrene  of  the  skin  of  part 
of  or  the  entire  limb  (third  degree). 

Anaemic  and  chlorotic  people  are  especially  susceptible  and  are  frost- 
bitten by  a  degree  of  cold  which  has  no  effect  upon  healthy  persons.  If 
the  gangrene  is  limited  to  the  skin,  cicatrization  sometimes  follows  after 
prolonged  ulceration,  such  as  is  common  if  the  destruction  is  deeper. 
Frost-bite  gangrene  of  large  areas  brings  all  the  dangers  of  septic  and 
toxsemic  complications  connected  with  every  case  of  gangrene  up  to 
the  time  of  demarcation. 

Prognosis. — The  prognosis  should  be  given  guardedly. 

Treatment. — The  treatment  depends  upon  the  severity  of  the  lesion 
and  is  on  general  principles.  If  there  is  extensive  "wet"  gangrene  and 
severe  symptoms  of  toxaemia,  life  may  be  saved  by  amputating  in  sound 
tissue.  In  cases  in  which  limitation  occurs  early,  demarcation  is  awaited 
and  then  amputation  performed. 

The  so-called  chilblain  is  characterized  by  chronic  circulatory  changes, 
diffuse  or  nodular  erythema,  and  swelling  with  intolerable  itching  in  a 
warm  atmosphere.  The  secondary  ulceration  from  scratching  may 
resist  all  treatment.  Disappearing  in  summer,  the  swellings  return  in 
the  fall  and  winter  with  the  same  annoying  symptoms.  The  well- 
intended  advice  "to  avoid  all  exciting  causes  as  much  as  possible"  is 
usually  rendered  impracticable  by  the  occupation  of  the  patient.  Baths 
with  a  slight  admixture  of  hydrochloric  acid;  protecting  the  skin  with 
ointment  or  plaster  if  there  are  ulcers;  the  silver  nitrate  stick,  and  pro- 
tective dressings,  may  be  tried  alternately. 

For  frost-bites  the  general  rule  is  the  application  of  gradually  increas- 
ing warmth  and  elevation  of  the  arm  to  overcome  venous  stasis.  The 
circulation  is  often  thus  restored,  so  that  parts  are  saved  in  which  gan- 
grene was  expected. 

It  is  impossible  to  estimate  with  certainty  just  how  far  the  result  of 
frost-bite  is  to  be  ascribed  to  mechanical  factors.  Ritter  regards  the 
hypersemia  as  an  attempt  at  repair  on  the  part  of  the  body  of  the  injury 


CHRONIC  INFLAMMATIONS  OF  HAND  AND  FINDERS.        333 

produced  by  the  cold.  The  hyperemia  results  from  capillary  attraction 
analogous  to  that  occurring  after  application  of  the  Esmarch;  it  has 
been  described  very  clearly  and  graphically  by  Bier.  Accordingly 
Hitter  recommends  Bier's  venous  congestion  method  for  acute  frost- 
bites, and  for  the  chronic  effects  of  the  cold,  arterial  hyperemia  by 
means  of  hot  air  applied  for  one-half  to  one  hour. 

Burns. — Burns  of  the  hand  and  their  treatment  are  to  be  regarded 
essentially  from  the  point  of  view  of  general  pathology  and  therapeutics. 
Especial  attention  should  be  called  to  the  severe  contractures  and 
synechia1  between  the  fingers  often  following  deep  burns.  Extension- 
contractures  of  the  fingers  are  especially  common  on  account  of  the 
frequency  with  which  the  dorsum  of  the  hand  is  affected.  Such  con- 
tractures are  prevented  very  little  by  antagonistic  dressings,  therefore 
grafting  should  be  done  as  soon  as  the  granulations  are  clean;  later, 
appropriate  passive  motion,  massage,  and  antagonistic  apparatus  may 
do  much  good.  Fully  established  contractures  demand  removal  of  the 
cicatrix  in  sound  tissue,  forcible  retraction  of  the  edges  of  the  wound, 
and  skin-grafts  or  flaps.  Even  then  the  result  is  permanent  only  when 
appropriate  exercises  follow  the  healing  over  of  the  surface.  Usually 
the  older  the  contracture  the  more  difficult  it  is  to  obtain  a  complete 
functional  result.  Nothing  can  be  done  if  there  are  changes  in  the 
joint  or  if  the  tendons  are  destroyed. 


CHRONIC  INFLAMMATIONS  OF  THE  SOFT  PARTS  OF  THE  HAND 

AND  FINGERS. 

Eczematous  and  mycotic-parasitic  affections  of  the  skin  have  passed 
more  and  more  into  the  domain  of  special  pathology.  Still  the  author 
feels  that  he  ought  not  to  omit  to  mention  that,  if  there  is  any  evidence 
that  the  disease  is  caused  by  a  local  agent  that  is  accessible,  recovery 
is  best  obtained  by  energetic  removal  of  the  latter — e.g.,  if  caused  by 
drugs,  by  removing  the  last  traces  chemically  (iodoform  by  ether) ;  if 
from  dirt,  by  thorough  mechanical  cleansing,  under  an  anaesthetic  if 
painful.  Of  the  diseases  of  the  nail  belonging  to  surgery,  the  subungual 
panaritium  has  been  discussed.  Chronic  affections  of  the  nail  now 
belong  to  dermatology.  The  pathology  of  the  nail  is  treated  compre- 
hensively in  J.  Heller's  Krankheitcn  der  Niigel. 

The  chronic  effects  of  subcutaneous  coccus  infections  and  furuncular 
and  septic  diseases  of  the  skin  are  usually  recognizable  by  their  local 
limitation,  the  history,  the  general  habit  of  the  patient,  the  fresh  granu- 
lations, or  the  profuse  suppuration.  Their  treatment  is  that  given  for 
panaritia. 

Tuberculosis  of  the  Skin. — Tuberculosis  occurs  in  the  skin  in  many 
forms.  The  dorsum  of  the  hand  and  fingers  is  the  usual  site.  The 
infiltration  may  develop  slowly,  the  skin  being  dry  and  scaly;  or  exist 
for  a  long  time  without  symptoms  of  acute  inflammation,  the  skin  being 
smooth,  of  brownish-red  color,  and  frequently  with  single  nodules  in 


334  DISEASES  OF  THE  WRIST  AND  HAND. 

the  adjacent  parts;  or  there  may  be  a  lupus  extending  diffusely  over 
hand  and  ringers  with  doughy  swelling,  thick  infiltration,  and  small  or 
large  superficial  ulcers,  the  base  of  the  ulcers  being  covered  with  dirty, 
milk-gray,  anaemic  granulations,  necrotic  in  places.  Or  the  tubercu- 
losis may  be  manifested  as  deep  ulcers,  the  size  of  a  quarter  or  dollar, 
with  eroded,  undermined  edges  and  uneven  base  covered  by  a  waxy 
membrane  if  neglected;  if  clean  dressings  are  applied,  the  secretion  may 
be  slight.  Lupus  is  especially  important  surgically  if  it  produces  ulcera- 
tion and  cicatrization  leading  to  contractures  and  mutilation  of  the 
fingers,  in  which  case  the  term  "lupus  mutilans"  is  proper,  v.  Langen- 
beck  at  the  Fourteenth  Surgical  Congress  was  able  to  demonstrate  only 
one  case;  Doutrelepont  reported  its  great  frequency  in  the  Rhine  districts; 
and  Kiittner  stated  that  in  19  cases  of  lupus  of  the  hand  obtained  from 
the  literature  of  forty  years  there  were  only  10  instances  of  contracture 


Deformity  due  to  lupus;  contracture  of  the  third,  fourth,  and  fifth  fingers  in  extension  and 
adduction  (ulnar  inflexion). 

and  deep  destruction.  In  spite  of  the  enormous  frequency  of  skin,  bone, 
and  joint  tuberculosis  in  Saxony  the  author  has  had  only  3  cases  of 
pronounced  mutilation  from  lupus  in  his  large  material  in  Leipzig. 
(See  Figs.  210  and  211.) 

As  lupus  occurs  and  spreads  chiefly  on  the  back  of  the  hand  and 
fingers,  the  hyperextension-contractures  develop  always  over  the  meta- 
carpophalangeal joints,  with  secondary  subluxation.  The  tendons 
generally  remain  intact,  the  cicatrix  in  the  skin  causing  the  contracture. 
The  inflammatory  changes  resulting  in  the  joints  are  not  tuberculous, 
but  are  deforming  processes  resulting  from  disuse;  they  may  produce 
complete  bony  ankylosis.  Sometimes  lupus  is  found  near  depressed 
bony  cicatrices  in  the  phalanges  or  metacarpals  or  near  corresponding 
fistulas.  In  all  the  above  forms  the  diagnosis  is  usually  supported  by 
the  general  habit  and  youth  of  the  patient,  and  by  suspicious  multiple 
lesions  on  the  rest  of  the  body.    It  is  different  in  the  cases  in  which  the 


CHRONIC  INFLAMMATIONS  OF  HAND  AND  FINGERS.       335 

history  and  symptoms  indicate  an  immediate  infection  of  the  skin  from 
without.  The  lesion  is  then  usuallythe  verrucous  or  hypertrophic  form. 
1  Pig.  212.)  The  active  proliferation  of  the  epithelium  is  manifested 
by  wart-like  growths,  or  there  may  be  bridges  or  a  grating  of  several 

Fig.  211. 


Lupus  mutilans,    (v.  Bruns.) 


bands  of  epidermis — due  to  partial  ulceration  of  the  dermis — which  can 
be  lifted  off  with  the  probe.  The  starting-point  of  this  process  was 
referable  almost  with  certainty  in  one  instance  to  a  cut  from  a  piece  of 
glass,  in  another  to  the  bite  of  a  cat,  and  in  5  others  to  the  occupational 


Fig.  212. 


Tuberculosis  verrucosa,     (v.  Bruns.) 


injury  of  butchers  who  had  come  in  contact  with  tuberculous  meat. 
Surgeons  and  dissecting-room  orderlies  are  exposed  to  a  special  form 
of  the  infection,  cadaver-tuberculosis,  developing  usually  in  the  form 
of  papillomata. 


336  DISEASES  OF  THE  WRIST  AND  HAND. 

Treatment. — The  author  is  glad  to  be  able  to  state  that  recently  more 
of  the  dermatologists  are  advocating  radical  treatment.  True  to  the 
principle:  tuberculosis  is  surgical  wherever  easily  accessible  and  remov- 
able without  severe  functional  loss,  the  author  recommends  excision 
of  the  parts  involved  and  grafting,  or  covering  in  with  pedunculated 
or  whole-skin  flaps.  After  carefully  excising  all  diseased  tissue  with  a 
margin  of  sound  tissue — avoiding  reinfection  of  the  wound — the  edges 
are  well  retracted,  the  fingers  immobilized  in  flexion  upon  a  splint,  and 
the  wound  grafted  so  that  the  space  covered  is  excessive  and  the  result- 
ing cicatricial  contraction  will  be  compensated.  The  author  has  also 
obtained  excellent  results  with  Krause's  corium-  or  whole-skin  flaps. 
The  author  has  never  seen  a  cure  with  the  .r-ray,  recently  so  widely 
recommended  for  the  treatment  of  lupus.  Kiimmell  and  others  report 
final  cures  by  irradiation,  the  cicatrix  being  particularly  satisfactory 
from  an  aesthetic  point  of  view. 

Typical  tuberculous  lymphangitis  of  the  upper  extremity,  arising 
from  tuberculous  affections  of  the  hand  or  fingers,  is  extremely  rare. 
Ever  since  Karg  and  Merklen  stated  in  1885  that  tuberculous  foci  on 
the  surface  of  the  body  could  cause  superficial  tuberculous  lymphangitis 
— lymphangitis  tuberculosa  externa — French  investigators  in  particular 
(Morel-Lavallee,  Lejars,  and  Goupil)  have  studied  and  described  the 
clinical  side  of  this  process.  Jordan  has  given  a  detailed  and  compre- 
hensive description  of  the  infection.  Many  of  the  patients  had  never 
had  tuberculosis  before  or  ever  been  sick.  The  larger  lymphatics  are 
changed  into  firm  cords,  soon  becoming  adherent  to  the  adjacent  tissues 
and  presenting  three,  five,  eight,  ten,  or  more  nodular  swellings  in  their 
course,  sometimes  in  the  form  of  a  rosary.  Later  the  thickenings  give 
fluctuation;  the  overlying  skin  becomes  attenuated,  of  a  bronze  or 
bluish  color,  scaly,  and  may  rupture  and  ulcerate.  The  corresponding 
glands  are  almost  always  infiltrated. 

Syphilitic  Affections. — These  are  either  primary  effects,  as  described 
above,  or  occur  in  the  form  of  fissures  with  a  waxy  coating,  and  develop 
into  chronic  paronychia  at  the  nails  or  in  the  interdigital  folds.  Gum- 
matous infiltration  is  rare  and  is  characterized  by  a  painless  flat  swelling, 
of  a  light-brown  color  projecting  above  the  surface,  and  usually  movable 
upon  the  underlying  parts. 

Dactylitis  syphilitica,  first  described  by  Liicke  as  a  disease  of  the 
fingers  in  the  tertiary  stage,  is  a  diffuse  uniform  thickening  of  several 
phalanges,  sometimes  of  several  fingers,  which  obliterates  all  the  folds 
of  the  skin.  It  advances  over  the  joints  and  involves  them.  The  skin 
is  usually  of  a  brownish,  copper  color,  red  at  the  onset,  at  the  same  time 
very  tense,  elastic,  and  almost  painless.  Although  the  process  may 
involve  the  capsule  of  the  joint  at  one  or  more  places,  motion  is  usually 
retained  and  without  crepitus.  This  circumstance  should  indicate  its 
relative  benignity,  and  on  longer  observation  be  decisive  against  tuber- 
culosis. The  diagnostic  importance  of  syphilitic  psoriasis  of  the  palm 
has  been  recognized  for  a  long  while.  Syphilitic  ulcers,  following  disin- 
tegration of  a  gumma,  with  soft,  elastic,  ragged  edges,  and  burrowing 


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CHRONIC  INFLAMMATIONS  OF  HAM)  AND  FINGERS.       337 

out   holes  in  the  skin,  are  occasionally  met  with   on  the  hack  of  the 
hand. 

Trophic  Disturbances.  Under  Serious  Results  of  Wounds  the 
author  mentioned  sonic  of  the  essentially  trophic  disturbances,  glossy 
skin,  atrophy  of  the  muscles*  There  is  also  a  rare,  severe  trophic  dis- 
turbance of  great  surgical  interest,  characterized  by  ulceration  and 
gangrene.  The  simplest  form  of  trophic  necrosis  and  ulceration,  and 
the  one  whose  etiology  is  best  known,  is  found,  especially  on  the  volar 
surface  of  the  fingers,  following  injuries  of  the  peripheral  nerves.  If  the 
site  of  division  of  the  nerve  is  beyond  the  exit  of  the  muscular  branches, 
the  disturbance  is  sensory — anaesthesia — not  motor-functional.  It  is 
characteristic  of  the  gangrene  following  such  wounds  that  it  is  very 
often  localized  in  the  skin  on  the  surfaces  of  the  finger  used  in  grasp- 
ing objects.  These  localized  trophic  ulcers  give  one  the  impression 
that  they  are  apparently  analogous  to  bedsores.  Suture  of  the  nerve 
brings  about  complete  recovery  if  not  done  too  late  after  the  injury. 

Fig.  213. 


Trophic  changes  in  the  thumb  and  index  finger  following  puncture-wound  of  the  median  nerve. 

Local  Effects  of  Syringomyelia  and  Leprosy. — These  diseases  cause 
severe  trophic  disturbances  in  the  skin  of  the  hand  and  fingers  and  on 
account  of  the  anaesthesia  lead  to  panaritia  and  phlegmon.  The  changes 
in  the  bones  and  joints  will  be  discussed  under  Chronic  Affections  of 
the  Bones.  The  changes  caused  by  gliomatosis — Morvan's  disease- 
sometimes  remind  the  author  of  the  analogous  diseases  already  men- 
tioned, namely,  analgesia  of  the  inflamed  and  suppurating  area,  usually 
complete;  simultaneous  nodular  swelling  of  the  joints;  deformities  and 
atrophy,  or  defects  in  the  phalanges.  The  examination  for  disturbances 
of  temperature-sense  and  muscular  atrophy  in  the  affected  limb-  always 
demonstrates  the  central  origin  of  the  disease.  In  4  of  the  author's 
cases  of  syringomyelia  occurring  between  the  twenty-first  and  forty- 
eighth  year  he  found  such  phlegmonous  affections.  The  swelling 
of  the  inflamed  area  always  suggested  a  low-grade  elephantiasis;  it 
usually  became  circular  rapidly,  and  was  characterized  by  its  slow  course 
and  persistent  elevations  of  temperature,  the  patient  being  not  essen- 
tially weakened  thereby.  The  patients  often  go  about  for  a  long  time 
with  such  panaritia,  as  the  disability  is  slight  on  account  of  the  analgesia. 

The  treatment  differs  from  that  of  the  otherwise  analogous  diseases 
Vol.   Ill— 22 


338 


DISEASES  OF  THE  WRIST  AND  HAND. 


Tig.  214. 


in  that  one  decides  more  easily  to  amputate  a  finger  or  part  of  it  to 
remove  the  deformity  and  cheek  the  process. 

Syringomyelia  and  leprosy  often  give  very  similar  symptoms  in  the 
hand,  The  panaritial  and  lymphangitie  processes  in  leprosy,  sometimes 
accompanied  by  analgesia,  are  of  interest  to  the  surgeon.  They  usually 
supervene  upon  the  ulceration  of  leprosy,  which  latter  is  characterized 
by  its  sluggishness,  rather  thin  discharge,  alternate  healing  and  recur- 
rence, later  involvement  of  the  bone  with  the  production  of  sequestra, 
and  possibly  loss  of  single  phalanges,  fingers,  or  even  the  hand  (lepra 
mutilans).  Or  there  may  be  wasting  of  the  tissues  with  almost  no  symp- 
toms of  inflammation,  but  with  the  production  of  the  above  deformities. 

Thus  the  terms  atrophy  and  con- 
sumption of  the  bones  of  the 
phalanges  have  been  applied. 
(Balz.)  There  may  be  spots  of 
dry  or  wet  gangrene.  (Kaposi.) 
The  rare  affections,  symme- 
trical gangrene  of  Raynaud  and 
ergotism,  are  of  only  slight  sur- 
gical interest,  although  their 
etiology  is  still  obscure. 

Kaposi  regards  the  sclerodac- 
tylia of  French  authors  (Ball, 
Hallopan,  and  Lepine)  not  as  a 
special  form  contrasted  to  the 
first  stage,  sclerema  with  thick- 
ening— sclerema  elevatum,  but 
rather  as  the  second  stage  of 
scleroderma — sclerema  atrophi- 
cans. In  it  the  skin  of  the  finger 
becomes  thinner,  like  parch- 
ment, glossy  red,  sprinkled  with 
pigment,  extremely  tense  and 
adherent.  The  entire  subcu- 
taneous fat-cushion  disappears, 
the  skin  is  like  stretched  rubber, 
and  the  underlying  bones  are  adherent.  Defects,  ulGers,  and  gangrene 
follow.  Recovery  at  this  stage  is  impossible.  Amputation  of  the 
affected  fingers  ameliorates  the  pain,  presupposing  that  it  is  limited  to 
the  finger  or  hand. 

Presenile  and  Senile  Gangrene. — These  affections  occur  more  fre- 
quently in  the  hand  and  fingers  than  in  the  toes  and  the  foot.  They 
may  be  signalized  by  nervous  and  circulatory  prodroma :  itching  increas- 
ing to  severe  pain,  sensation  of  coldness,  and  some  rigidity  during  active 
movements.  After  ischa?mia  has  existed  for  some  time  small  sero- 
purulent  vesicles  appear,  accompanied  by  anaesthesia  and  severe  pain, 
and  followed  by  dry  gangrene  and  total  necrosis  of  one  or  more 
fingers. 


Deformation  of  the  hand  due  to  syringomyelia, 
(v.  Bruns.) 


CHRONIC  INFLAMMATIONS  OF  HANI)  AM)  blNOKIlS. 


339 


What  is  termed  spontaneous  gangrene  is  usually  the  result  of  a,  hyaline 
thrombosis  (v.  Recklinghausen ),  or  an  embolus  in  tissue  normal  up  to  its 
site,  whereas  senile  gangrene  is  always  associated  with  arteriosclerosis 
and  follows  the  gradual  development  of  changes  in  the  circulation. 
The  picture,  as  drawn  by  v.  Winiwarter,  of  obliterating  endarteritis  with 
subsequent  gangrene,  in  which  there  is  primarily  a  growth  of  the  intima, 
is  regarded  by  v.  Zoge-Manteuffel  and  his  pupil  Weiss  as  signifying  that 
the  occlusion  of  the  vessel  is  due  to  thrombosis  of  the  vessel  at  the  site 
of  changes  produced  by  the  sclerosis.  Based  upon  investigations  in  v. 
Eiselsberg's  clinic, Bunge  sides  with  v.  Zoge-Manteuffel,  in  that  he  regards 

Fig  215 


X-ray  picture  of  Fig.  214 


the  diffuse  or  localized  sclerotic  changes  of  the  intima  and  the  ascending 
thrombosis  due  to  the  resulting  stenosis  as  the  essentials  of  the  process. 
Although  these  changes  in  the  vessel  are  of  greater  vital  significance  in 
the  lower  extremities,  their  knowledge  is  indispensable  in  diagnosticating 
analogous  affections  in  the  fingers. 

Diabetic  Gangrene. — Gangrene  of  the  fingers  or  hand  in  diabetes 
is  more  serious  and  usually  extends  rapidly.  Slight  wounds,  small 
unnoticed  scratches,  permitting  the  entrance  of  bacteria,  may  be  the 
starting-point  of  extensive  destruction  of  the  tissues.  This  phlegmonous 
necrotic  form  of  gangrene  must  be  distinguished  from  the  less  frequent 


340 


DISEASES  OF  THE  WRIST  AND  HAXD. 


variety  occurring  without  injury,  and  in  which  presumably  there  are 
important  changes  in  the  vessels,  as  in  the  presenile  variety. 

Konig  and  Kraske  have  demonstrated  that  in  phlegmonous  diabetic- 
necrosis  there  must  be  an  external  cause — bacteria — in  addition  to  the 
internal  cause  of  diabetes.  The  recent  investigations  (v.  Xoorden,  Xau- 
nyn,  Gross,  and  others)  of  carbuncles  have  confirmed  this  and  proved 
that  the  foudroyant  necrotic  diabetic  phlegmon  is  always  accompanied  by 
pyogenic  cocci,  almost  always  Staphylococcus  aureus,  rarely  albus.  The 
author  has  also  made  the  bacteriological  control  in  quite  a  few  cases.  The 
necrosis  reminds  one  of  the  white,  glossy,  gelatinocaseous  necrosis  pro- 
duced by  Vienna  paste.  In  dry  gangrene,  possibly  in  the  diabetic  form 
produced  by  arteriosclerotic  changes  in  the  vessels,  there  is  a  parchment- 
like eschar.  Xaunyn  saw  a  man  seventy  years  old  with  ulcers  on  the 
right  index  and  little  finger  similar  to  perforating  ulcer,  with  sharp 
border  and  waxy  base,  which  were  referable  to  diabetes;  the  ulcers  were 

Fig.  216. 


Diabetic  gangrene  of  the  dorsum  of  the  hand. 


found  healed  at  the  end  of  eleven  months.  Gross  has  recently  published 
a  careful  monograph  on  diabetic  gangrene  and  collected  49  instances  of 
so-called  idiopathic  gangrene  in  50  cases  of  inflammatory  necrosis  of  the 
extremities;  35  were  in  the  lower,  15  in  the  upper.  In  36  there  was 
latent  diabetes.  The  age  varied  between  twenty-eight  and  seventy- 
three;  the  percentage  of  sugar  from  0  to  10  per  cent. 

In  the  idiopathic  forms  the  gangrene  begins  usually  in  the  peripheral 
parts  of  the  extremity,  the  finger-tips;  in  inflammatory  diabetic  necrosis 
it  is  located  anywhere  in  the  hand,  depending  on  the  site  of  the  etiolog- 
ically  important  but  slight  injury.  In  Fig.  216  is  shown  a  case  of  acute 
diabetic  inflammatory  necrosis  on  the  back  of  the  hand  which  was 
under  careful  observation  from  the  onset.  There  was  6.7  per  cent,  of 
sugar.  In  six  days  the  extensor  tendons  were  denuded  of  skin  over  a 
large  area  and  partly  involved  in  the  necrosis.  The  process  then  stopped 
and  recovery  followed  without  radical  surgical  measures. 


PLATE    XII 


Carbolic  Gangrene  of  Finger.     (Harrington. 


CHRONIC  INFLAMMATIONS  OF  HAND  AND  FINGERS.        341 

Treatment. — In  1884  J.  Hutchinson  proposed  high  amputation — 
shoulder-joint — for  all  cases  of  senile  and  diabetic  gangrene.  In  1891 
L.  Heidenhain  made  a  similar  proposal  in  regard  to  the  lower  extremity. 
The  indication  fixed  by  F.  Konig  in  1887  may  be  presented  as  the  one 
generally  adopted  at  the  present  time  by  German  surgeons  for  surgical 
treatment,  namely,  individualization  from  case  to  case  and  the  trans- 
formation of  the  septic  necrosis  as  far  as  possible  into  an  aseptic  wound. 
If  phlegmon  occurs,  it  should  be  incised  and  the  necrotic  parts  removed 
as  much  as  possible  without  injuring  the  still  intact  tissues.  If  the 
gangrene  advances  in  spite  of  antidiabetic  and  appropriate  local  treat- 
ment and  the  general  condition  is  evidently  worse,  the  preservation  of 
life  demands  high  amputation,  the  author  adds,  without  general  anaes- 
thesia— diabetic  coma — but  by  using  morphine  and  local  anaesthesia. 
In  the  author's  experience  the  amount  of  sugar  is  not  decisive  for  the 
time  and  extent  of  operation,  but  under  all  circumstances  should  deter- 
mine the  energy  of  the  antidiabetic  diet. 

Fig.  217. 


Line  of  demarcation  of  gangrene  due  to  carbolic  acid. 

Carbolic  Gangrene. — The  author  desires  to  mention  here  an  artificial 
form  of  gangrene,  the  occurrence  of  which,  in  no  respect  less  frequent  at 
the  present  time,  is  due  to  the  faith  of  physicians  and  the  laity  in  the 
omnipotence  of  carbolic  acid.  The  fact  that  solutions  of  carbolic  acid  are 
still  sold  at  retail  without  a  prescription,  the  ambiguous  directions  of  the 
physician  for  its  use,  and  ignorance  or  misunderstanding  on  the  part  of 
the  patient,  are  responsible  for  the  present  existence  of  carbolic  gangrene. 
According  to  the  statistics  of  Honsell  in  1897,  comprising  only  48  cases 
— the  author  has  at  least  4  or  5  new  cases  every  year — the  strength  of 
the  solution  used  was  1  to  5  per  cent,  in  30  cases  and  concentrated  in  31. 
It  is  of  special,  practical  importance  to  know  that  gangrene  may  be  pro- 


342  DISEASES  OF  THE  WRIST  AND  HAND. 

duced  by  the  application  of  a  1  per  cent,  solution  for  twenty-four  hours 
(case  of  v.  Brims  and  Peraire),  in  twelve  hours  by  a  2  per  cent,  solution 
(case  of  Levai),  and  in  three  to  four  hours  if  more  concentrated  (case 
of  Kortiim).  Without  attempting  to  describe  or  analyze  the  various 
efforts  made  to  determine  the  pathogenesis  of  carbolic  gangrene — Kor- 
tiim regarded  the  cause  as  neuroparalytic — the  author  regards  Franken- 
burger's  explanation  as  most  worthy  of  consideration:  the  epidermis  is 
destroyed,  the  subcutaneous  tissue  shows  considerable  transudation, 
the  contents  of  the  lymph-  and  blood-vessels  are  coagulated;  gangrene 
follows  the  thrombosis  of  the  vessels.  The  experiments  of  Levai  and 
Honsell  make  it  very  probable  that  the  action  of  carbolic  acid  is  not  a 
specific  one,  but  is  analogous  to  that  produced  by  mineral  acids. 

The  danger  threatened  by  the  changes  is  little  recognized  by  the 
patient:  itching  and  paresthesias  merge  slowly  or  rapidly  into  anaes- 
thesia. The  former  is  regarded  by  the  patient  as  an  expression  of  the 
healing  process;  the  latter  deceives  him  as  to  the  danger.  A  dull  feel- 
ing of  pain  is  perhaps  provocation  for  changing  the  dressing,  previously 
so  soothing;  the  finger  is  yellowish-white  or  brownish,  stiff,  cold,  and 
without  feeling;  gangrene  is  complete.  Individual  disposition  probably 
plays  a  certain  part,  as  the  author  remembers  in  his  experience  in  the 
period  when  carbolic  acid  was  still  used  in  the  treatment  of  wounds 
and  a  difference  in  toleration  was  noticed.  The  only  measures  to  be 
considered  are  amputation,  exarticulation,  or  to  wait  for  demarcation. 


DISEASES  OF  THE  TENDON-SHEATHS  AND  BURSjE  OF  THE  HAND 

AND  FINGERS. 

On  diagnostic  and  practical  grounds  the  acute  inflammations  and 
suppuration  of  the  tendon-sheaths  of  the  hand  and  fingers  were  consid- 
ered under  Panaritium,  to  which  the  reader  is  referred  for  the  acute 
inflammatory  processes  of  traumatic  and  infectious  origin. 

Acute  serous  tenosynovitis  is  often  seen  as  an  affection  of  the  extensor 
tendons  of  the  thumb  accompanied  by  crepitus  on  motion  (tendovagi- 
nitis crepitans).  It  results  from  trauma  or  overexertion,  and  is  frequently 
seen  in  women  of  the  laboring  classes  (washerwomen,  charwomen); 
among  men  it  is  more  common  in  joiners,  carpenters,  and  locksmiths. 
It  is  characterized  by  a  swelling  corresponding  to  the  course  of  the 
extensor  tendons  of  the  thumb,  and  may  apparently  involve  the  muscles. 
The  crepitus,  from  which  the  disease  derives  its  name,  is  caused  by 
loosening  of  the  synovialis  and  by  thin  deposits  of  fibrin.  Rest  usually 
brings  about  recovery  in  a  few  days  or  at  least  alleviates  the  pain;  if 
protracted,  massage  and  use  are  beneficial. 

Extravasation  of  blood  may  occur  in  the  large  volar  tendon-sheath 
beneath  the  transverse  carpal  ligament,  in  the  common  extensor  sheath 
on  the  dorsum,  and  in  the  sheaths  of  the  extensors  carpi  radialis,  in 
connection  with  contusion  of  the  wrist  or  fracture  of  the  radius.  The 
tension  may  cause  severe  pain  and  the  restricted  movements  of  the  ten- 


DISEASES  OE  TENDON-SHEATHS  OE  HAND  AND  FINGERS.     343 

dons  occasion  functional  loss.  The  conformation  of  the  swelling  depends 
naturally  upon  its  situation  and  extent.  Traumatic  serous  effusion  is 
often  seen  at  a  later  period  after  injury — e.  cj.,  in  the  common  flexor 
tendon-sheath  after  fracture  uniting  with  displacement,  the  tendons  pass- 
ing over  the  point  of  fracture  as  over  a  fulcrum  and  being  thus  subjected 
to  constant  pressure  during  motion.  It  also  follows  subcutaneous  injury 
of  the  tendon  which  has  produced  cicatricial  thickening  of  the  tendon  or 
other  palpable  changes. 

Tuberculosis  and  (/ouorrlura,  exceptionally  syphilis,  are  the  most  fre- 
quent causes  of  large  effusions  in  the  tendon-sheaths  of  the  hand  and 
fingers.  The  characteristic  form  and  extent  of  the  swelling  in  traumatic 
and  acute  infectious  diseases  of  the  tendon-sheath  have  already  been  em- 
phasized as  important  in  the  diagnosis;  these  characteristics  are  even 
more  striking  in  chronic  inflammations  of  the  tendon-sheaths.  The  form 
of  the  swelling  on  the  volar  surface  of  the  finger  down  to  the  base  of  the 
end-phalanx  is  particularly  well-defined;  it  may  be  less  distinct  if  con- 
fined to  the  palm,  namely,  to  the  distal  portion  of  the  common  flexor 

Fig.  218. 


J 


Hygroma  carpi  tuberculosum.    (v.  Bruns.) 

sheath.  In  the  latter  situation  it  has  naturally  to  overcome  the  resist- 
ance of  the  palmar  aponeurosis;  the  hollow  of  the  palm  maybe  partly 
or  entirely  effaced;  in  fact,  the  skin  may  bulge  convexly.  Usually,  how- 
ever, the  inflammation  and  effusion  extend  throughout  the  entire  flexor 
sheath  and  upward  under  the  transverse  carpal  ligament,  ending  above 
in  a  curve  convex  upward. 

The  term  " pursc-hygroma"  (Zwerchsackhygrom)  was  frequently  ap- 
plied formerly,  without  regard  to  the  etiology,  to  the  hour-glass-shaped 
fluctuating  tumor  bulging  above  and  below  the  transverse  carpal  liga- 
ment. The  peculiarity  of  the  swelling  is  the  through-fluctuation  beneath 
the  ligament.  Often  one  can  feel  free  or  pedunculated  rice  bodies — 
corpora  oryzoidea — in  the  sac.  Their  almost  constant  tuberculous 
origin  was  first  demonstrated  by  Konig  and  Riedel,  and  later  confirmed 
by  numerous  investigators  (Goldmann,  Garre,  and  others).  The 
analogous  process  is  seen  rather  often  in  the  common  dorsal  tendon- 
sheath  of  the  extensors  or  in  one  of  the  smaller  dorsal  sheaths.  The 
author  has  repeatedly  seen   symmetrical    tuberculous  effusions  in  the 


344 


DISEASES  OF  THE  WRIST  AND  HAND. 


large  dorsal  and  volar  sacs,  which  were  spongy  and  bulging;  once  there 
was  simultaneous  effusion  in  the  tendon-sheaths  over  the  ankle-joint. 
It  is  remarkable  that  these  multiple  affections  of  the  tendon-sheaths 
often  occur  in  persons  who  otherwise  show  no  sign  of  tuberculosis. 
This  circumstance  may  excuse  the  fact  that  they  are  often  regarded 
as  articular  rheumatism  and  treated  as  such;  still,  the  error  can  only 
arise  from  careless  examination. 

The  tuberculous  swelling  may  occur  in  the  form  of  a  serous  effusion, 
or  with  rice  bodies,  or  as  the  doughy,  fungous  variety.  These  three  forms 
may  represent  three  stages  in  the  course  of  one  and  the  same  disease, 
so  that  they  merge  into  each  other  and  cannot  always  be  distinguished. 
The  first  and  second  categories  may  continue  for  months  without  change 
and  without  troubling  the  patient  especially;  in  other  cases  the  disease 

Fig.  219. 


Total  excision  of  tuberculous  tendon-sheaths  (taken  during  operation) 


may  be  in  the  form  of  doughy  and  more  or  less  circumscribed  foci  from 
the  start,  and  when  the  adjacent  tissues  are  apparently  involved  it 
should  arouse  suspicion  that  the  joint  may  be  affected.  This  latter 
form  almost  always  advances  steadily  to  the  formation  of  cold  abscesses, 
perforation,  and  fistulas. 

Injection  of  iodoform  and  similar  measures  work  wonders  in  some 
cases,  in  others  they  fail  entirely,  and  the  process  advances — often 
apparently  more  rapidly.  If  the  tendon-sheath  is  opened,  the  picture  of 
the  destruction  is  complete:  the  reddish-blue,  spongy,  swollen  synovialis 
shows  punctate  or  diffuse  degeneration,  the  cavity  is  filled  with  pus  and 
small  necrotic  particles.  In  the  serous  form,  iodoform,  as  mentioned, 
is  of  incontestable  value.     The  rice  bodies  can  be  removed  to  a  large 


DISEASES  OF  TENDON-SHEATHS  OF  HAM)  AND  FINGERS.     345 

extent  by  scraping  out  the  tendon-sheaths.  In  the  severest  fungous  form 
with  disintegration, radical  extirpation  of  the  sheaths  rarely  fails.  The 
Cases  in  which  careful  dissection  of  all  or  almost  all  the  tendon-sheaths 
of  the  palm  was  indicated  were  numerous,  and  after  some  experience 
the  author  can  say  with  satisfaction  that  the  functional  recovery  of  the 
hand  was  gratifying  in  every  case,  and  often  remarkable.  Fig.  21!)  is 
a  picture  of  a  case  of  very  extensive  tuberculosis  of  the  tendon-sheaths, 
taken  during  operation,  after  complete  removal  of  all  diseased  tissue. 
It  was  the  left  hand  of  a  laborer.  Today,  at  the  end  of  three  and 
one-half  years,  lie  has  his  full  earning-efficiency. 

If  left  to  themselves,  tuberculous  inflammations  of  the  tendon-sheaths 
show  little  tendency  to  recovery,  but  increase  slowly  or  rapidly  with 
loss  of  function  and  all  the  symptoms  described  above.  Following  per- 
foration and  the  formation  of  fistulas,  the  tuberculous  "tumor"  shrinks 
partially  and  the  patients,  especially  if  advanced  in  years  and  the  affec- 
tion is  on  the  left  hand,  are  more  pleased  with  the  result  than  with  any 
plan  of  operation.  It  is  also  in  old  age,  where  active  proliferation  of 
connective  tissue  against  the  inflammatory  process  is  often  absent,  that 
iodoform  often  fails  to  act;  on  the  other  hand,  total  extirpation  is  less 
advisable  for  very  much  the  same  reason.  A  single  small  incision  may 
be  made  to  bring  about  the  desired  decrease  in  the  swelling,  although 
fully  recognizing  that  its  action  is  merely  palliative.  Immobilization, 
baths,  care  of  the  fistulas,  and  injections — 1  per  cent,  solution  of  silver 
nitrate — make   the  condition   more  tolerable  to  the  patient. 

Gonorrhoea!  inflammation  of  the  tendon-sheaths  is  frequently  seen 
among  the  large  material  of  great  cities.  It  is  more  common  in  men 
than  in  women,  analogous  to  gonorrhoeal  arthritis.  It  occurs  commonly 
in  the  third  week  to  the  third  month  of  the  urethritis,  often  acute,  with 
very  severe  pain  and  corresponding  symptoms  of  inflammation,  or  it 
is  more  subacute.  The  rapid  involvement  of  the  adjacent  tissues, 
(edema,  and  the  serous  exudation  in  the  corresponding  muscles  are 
characteristic.  Further,  the  involvement  of  a  single  joint,  with  evidence 
of  gonorrhoea,  in  youthful  individuals  otherwise  healthy,  the  rapid  loss 
of  function,  the  darting  pains  of  the  inflammation,  make  the  diagnosis 
comparatively  simple.  The  pain  in  the  acute  stage  may  be  so  severe  that 
aspiration  of  the  inflammatory  exudate,  as  in  gonorrhoeal  hydrocele 
from  epididymitis,  repeated  within  a  fewr  days,  is  the  most  effective 
measure  against  it.  The  author  has  never  found  provocation  for  further 
operative  measures  in  gonorrhoeal  affections  of  the  tendon-sheaths. 
Absolute  immobilization  for  one  to  three  weeks,  then  an  effective  course 
of  movements,  is  the  therapeutic  cardinal  regime  of  these  affections. 
The  author  immobilizes  generally  upon  a  plaster  or  pasteboard  splint, 
exerts  slight  compression  in  applying  the  bandage,  and  advises  elevation 
of  the  arm  and  ice  upon  the  hand.  No  time  should  be  lost  in  commenc- 
ing motion  after  the  pain  has  disappeared.  Otherwise  neglect  is  paid 
for  by  ankylosis  and  functional  impairment  for  a  long  period.  There 
is  a  great  tendency  to  adhesions,  on  account  of  the  pronounced  pro- 
liferative reaction  of  the  connective  tissue. 


346  DISEASES  OF  THE  WRIST  AND  HAND. 

Syphilitic  affections  of  the  tendon-sheaths  are  rare.  They  are  usually 
seen  in  the  secondary  and  tertiary  stages,  and  are  characterized  by 
uniform  elastic  resistance  or  flat  exudates.  Functional  impairment  is 
usually  absent.  The  other  manifestations  of  lues  are  generally  not  want- 
ing, especially  in  the  periosteum  and  bones  (skull,  long  bones);  also 
gumma  of  the  muscles  (trapezius,  sternocleidomastoid,  pectoralis,  etc.). 
The  iodides  are  of  first  importance. 

Bursas  are  rarely  found  developed  on  the  dorsum  of  the  hand  or 
fingers;  they  are  occasionally  seen  over  the  interphalangeal  joints  in 
laborers.  Inflammatory  effusion  in  a  bursa  may  simulate  an  affection 
of  the  joint.  Chronic  thickening  of  the  walls  leads  to  the  formation  of 
a  small,  round  hygroma,  which  may  require  operation. 


DISEASES  OF  THE  JOINTS  AND  BONES   OF  THE  HAND. 

Acute  Inflammation  of  the  Joints  and  Bones  of  the  Hand. — Acute 
inflammation  of  the  wrist-joint,  as  of  all  the  joints,  begins  with  effu- 
sion and  sharp,  throbbing,  weakening  pain.  All  acute  exudates  distend 
the  capsule  throughout,  so  that  at  all  spots  where  its  distensibility  is 
not  limited  by  tendons  and  ligaments  it  bulges  more  or  less  distinctly 
at  both  sides  of  the  extensor  and  flexor  tendons.  Through-fluctuation 
from  the  dorsum  to  the  volar  surface  is  frequently  palpable.  Large 
exudates  force  the  hand  into  a  position  of  slight  flexion  and  usually 
moderate  ulnar  adduction.  The  tendon-sheaths  are  compressed,  the 
tendons  less  movable,  and  movements  of  the  fingers  are  painful.  The 
soft  parts  covering  the  joint  are  usually  oedematous,  red,  and  tense. 
The  affection  can  be  mistaken  for  one  of  the  soft  parts  or  of  the  tendon- 
sheaths  alone;  but  the  circular  character  of  the  swelling,  the  pronounced 
functional  loss,  the  usually  intense  pain,  not  infrequently  accompanied 
by  high  fever,  leave  no  doubt  as  to  the  presence  of  an  affection  involving 
the  joint. 

Traumatic  exudates,  characterized  by  sanguineous  or  serosanguineous 
fluid,  are  not  to  be  regarded  essentially  as  inflammatory.  Earlier  they 
were  not  always  sharply  distinguished  from  genuine  inflammations,  but 
the  present  accurate  conception  of  the  etiology  and  the  infectious  char- 
acter of  all  acute  inflammations  of  the  joint  make  the  distinction  possible. 

"Rheumatism,"  an  acute  infectious  disease  of  the  joints  whose 
etiology  is  uncertain,  is  a  subject  for  internal  treatment.  Surgical 
treatment  will  be  required  only  for  immobilization,  prevention  of  de- 
forming contractures,   or  the  improvement  of  existing  deformities. 

Gonorrhoea,  in  the  majority  of  cases,  is  the  cause  of  the  monarticular 
inflammations  regarded  earlier  as  rheumatic.  The  inflammatory  ex- 
udate in  the  joints  of  the  hands  and  fingers  usually  appears  at  the 
earliest  in  the  fourth  week  of  the  acute  urethral  infection,  and  in  the 
later  course  of  the  disease  generally  in  the  second  to  third  month  after 
the  onset.  Occurring  later  in  the  course  of  chronic  urethritis,  it  often 
follows  instrumentation  or  irrigation  of  the  urethra.    The  large  majority 


DISEASES  OF  THE  JOINTS  AND  BONES  OF  THE  HAND.     JJ47 

of  cases  arc  male  patients.  The  affection  is  characterized  by  early 
involvement  of  the  adjacent  tendon-sheaths,  serous  infiltration  of  the 
soft  parts,  and  an  indistinct  picture  of  an  intra-articnlar  inflammation. 
It  has  a  marked  tendency  to  produce  early  ankylosis  and  inflammation 
of  the  cartilage  with  crepitus.  Symptoms  of  sepsis  are  rare.  The  above 
symptom-complex  is  repeated  in  all  cases,  with  varying  acuteness  of 
the  symptoms  and  intensity  of  the  pain. 

The  prognosis  of  a  gonorrhoea!  joint  is  usually  good,  providing  that  the 
treatment  begins  early  and  not  in  the  stage  of  ankylosis  or  pronounced 
crepitus.  If  the  surgeon  confines  himself  closely  to  the  therapeutic 
regime  mapped  out  by  Nasse,  gonorrhoea!  arthritis  of  the  hand  and 
finger-joints  presents  a  grateful  domain  for  treatment.  The  plan  of 
treatment  culminates  in  two  chief  points:  careful  immobilization  in  the 
stage  of  acute  pain  and  prompt  commencement  of  motion  after  the 
pain  subsides;  or,  to  express  it  more  clearly  as  to  time:  absolute  immo- 
bilization till  the  third  or  fourth  week,  then  gentle  passive  motion,  and 
later  active  exercise.  If  there  are  considerable  tension  and  pain,  aspira- 
tion, partial  or  total,  with  a  Pravaz  or  a  larger  needle,  gives  relief.  It 
may  be  done  at  the  wrist,  at  either  side  of  the  flexors,  and  repeated  two 
or  three  times.  The  author  usually  aspirates  at  the  same  point  used 
for  injecting  iodoform,  namely,  below  the  styloid  process  of  the  ulna. 

In  septic  infection  the  treatment  must  be  more  energetic,  regardless 
as  to  whether  the  condition  is  due  to  penetrating  wounds,  phlegmon, 
tenosynovitis,  adjacent  osteomyelitic  foci,  metastases,  or  a  general  in- 
fectious disease.  The  rapid  exudation,  existing  under  high  pressure, 
may  be  the  starting-point  of  further  severe  complications,  the  long 
protracted  septic  synovitis  being  almost  always  followed  by  synovial 
synechia?.  The  time  at  which  the  cartilage  is  destroyed  is  beyond  cal- 
culation. On  the  other  hand,  early  removal  of  the  exudate  and  the 
establishment  of  drainage  may  mean  full  recovery  of  function.  The 
wrist-  and  ankle-joint  are  particularly  unfavorable  for  drainage.  Some- 
times two  large  lateral  incisions,  1  to  l\  inches  long,  at  the  sides  of  the 
extensor  tendons  are  sufficient;  then  again  they  do  not  insure  drainage, 
and  the  question  arises:  To  resect,  and  how  far?  The  decision  will 
depend  more  upon  the  experience  of  the  individual  and  the  severity  of 
the  case  than  upon  any  categorical  paradigm.  In  the  majority  of  cases 
of  phlegmon  or  other  inflammation  involving  the  joint  the  incision  as 
given  and  drainage — rather  than  packing — are  sufficient.  If  pyaemic 
metastasis  occurs,  the  patient  sometimes  succumbs  to  the  effect  of  mul- 
tiple foci  elsewhere,  whether  resection  is  done  or  not.  The  pathological 
processes  in  the  joint  are  best  overcome,  if  sufficient  drainage  cannot  be 
obtained,  by  removing  one  or  more  carpal  bones.  One  should  be  warned 
against  total  resection,  especially  with  simultaneous  removal  of  the  lower 
ends  of  the  bones  of  the  forearm,  unless  the  condition  demands  such 
imperatively.  The  result  is  usually  discouraging  if  the  infection  is 
severe,  even  at  the  present  time  and  in  spite  of  drainage  or  packing. 
On  the  other  hand,  excessive  conservatism  in  septic  infection  has  its 
evil  consequences.     This  applies  particularly  to  delaying  incision  of 


348  DISEASES  OF  THE  WRIST  AND  HAND. 

the  joint,  for  the  anatomical  relations  are  unfavorable  for  aspirating 
and  injecting  antiseptics,  and  the  neglect  will  often  be  regretted  if  paid 
for  by  permanent  ankylosis.  It  will  be  very  unusual  if  sepsis  of  the 
wrist-joint  cannot  be  controlled  by  the  above  measures  and  if  ampu- 
tation of  the  forearm  becomes  necessary.  After  incising,  the  hand  is 
slightly  flexed,  immobilized,  and  elevated,  the  patient  being  recumbent. 

Osteomyelitis  of  the  radius  may  cause  secondary  effusion  in  the 
joint.  The  latter  should  be  treated  like  the  infectious  exudations 
if  aspiration  of  the  joint  has  verified  the  character  of  the  exudate — 
serous,  flocculent,  purulent — especially  with  reference  to  the  bacteri- 
ology. The  author  has  frequently  found  secondary  effusions  in  the 
joint  without  bacteria,  in  osteomyelitis  of  the  tibia  and  femur — as  well  as 
of  the  radius — and  the  further  course  justified  the  conservative  treatment. 
After  disposing  of  the  primary  osseous  focus  the  effusion  disappeared 
spontaneously  without  aid  and  without  leaving  fibrous  ankylosis.  If 
the  osteomvelitic  focus  is  in  one  of  the  carpals — a  rare  occurrence — the 
treatment  should  be  that  of  osteomyelitis  and  the  bone  removed  if  neces- 
sary. The  same  applies  to  foci  in  the  metacarpals  or  the  phalanges; 
they  are  often  complicated  by  septic  arthritis  of  the  adjacent  joints. 

Chronic  Inflammation  of  the  Bones  and  Joints  of  the  Hand. — 
Chronic  inflammations  of  the  bones  and  joints  of  the  hand  are  most 
often  met  with  in  the  form  of  chronic  articular  rheumatism,  arthritis 
deformans,  and  gout  (arthritis  uratica).  Frequent  as  is  the  occurrence 
of  chronic  articular  rheumatism  in  the  wrist,  the  metacarpophalangeal 
and  interphalangeal  joints,  it  rarely  produces  changes  requiring  surgical 
treatment.  The  multiplicity  of  the  more  or  less  painful  inflammations 
of  the  joints,  developing  slowly  with  effusion,  but  without  the  doughy 
covering  of  the  soft  parts  of  tuberculous  affections,  will  rarely  be  the 
cause  of  diagnostic  error. 

Arthritis  Deformans. — Deforming  arthritis  is  distinguished  by  nod- 
ular thickening  of  the  interphalangeal  joints,  by  lateral — usually  ulnar — 
and  volar  subluxation,  chiefly  in  the  wrist  and  metacarpophalangeal 
joints,  and  by  the  rapid  loss  of  funcrion  of  the  fingers,  even  to  complete 
disability.  Lateral  displacement  of  the  extensor  tendons  and  secondary 
shortening  of  the  corresponding  muscles  often  combine  to  produce  in 
a  short  space  of  time  deformities  of  the  hand  and  fingers  that  cannot 
be  corrected.  Although  the  greater  number  of  patients  are  of  advanced 
age,  the  changes  in  the  joint  may  reach  a  severe  grade  in  middle  life, 
even  at  the  twentieth  year,  almost  always,  however,  in  women.  The 
surprising  fact  in  the  history,  that  there  is  often  a  rapid  transition  from 
full  power  of  the  hand  during  relative  disuse,  would  indicate  that  at 
the  beginning  of  the  process  renewed  use  of  the  hand  would  be  more 
efficacious  in  preventing  further  changes  than  rest.  Corrective  treat- 
ment is  out  of  question  if  ulnar  adduction  and  volar  subluxation  are 
established.  The  initial  stage  belongs  to  internal  medicine  and  saves 
further  description. 

Gout. — Gout  in  the  fingers  more  frequently  leads  to  errors.  Although 
the  acute   attacks  are  rarer  here  than  in  the  toes,  an  acute  swelling 


DISEASES  OF  THE  JOINTS  AND  BONES  OF  THE  HAND.      349 

of  the  joint  accompanied  by  intense  pain  and  redness  and  without 
involvement  of  the  lymphatics  must  be  regarded  as  an  acute  attack 
of  gout.  The  diagnosis  is  simplified  as  soon  as  the  intra-articular  and 
periarticular  deposits  of  urates  are  recognizable  on  palpation  by  the 
sand-like  grating,  or  if  circumscribed  yellow  foci  are  evident  in  the 
inflamed  skin,  or  if  with  the  high-grade  acute  inflammatory  swelling 
there  is  a  more  solid  than  fluctuating  infiltration.  The  above-mentioned 
absence  of  the  simultaneous  signs  of  lymphadenitis  which  so  frequently 
accompany  phlegmonous,  septic  arthritis,  the  healthy  appearance  of 
the  patient,  and  the  points  of  the  history,  together  with  the  local  symp- 
toms, prevent  error  and  wrong  treatment. 

The  incision  of  gouty  nodules  is  only  justifiable  if  there  is  a  very 
great  deposit  of  urates  extending  to  the  surface,  or  for  the  alleviation 
of  pain.  The  discharge  of  urates  and  the  indolent  character  of  the 
secretion  will  certainly  lead  to  the  right  diagnosis  if  it  was  previously 
wrong.  Gout  may  produce  high-grade  deformities  in  the  fingers  and 
volar  and  ulnar  deviation  in  the  metacarpophalangeal  joints.  The 
value  of  exercise,  massage,  and  hydrotherapy,  in  addition  to  internal 
medication,  is  generally  recognized.  For  further  details  the  reader  is 
referred  to  the  text-books  on  general  medicine. 

Hereditary  Syphilis. — The  congenital  luetic  diseases  of  the  bones  and 
joints  of  the  hand  resemble  tuberculosis  clinically  very  closely.  The 
diagnosis  is  simplified  if  syphilitic  changes  are  found  in  other  parts  of 
the  body:  skull,  nose,  gums,  anus,  interdigital  folds.  In  other  cases 
the  family  history,  observation  of  the  course  of  the  symptoms,  and  a 
tendency  to  retrogression  without  softening  or  perforation,  are  of  diag- 
nostic importance.  The  individual  foci  on  the  metacarpals  or  phalanges 
may  be  so  slightly  distinguishable  clinically  from  tuberculosis  that  the 
diagnosis  must  often  be  deferred  for  a  time:  in  the  joints  the  involvement 
chiefly  of  the  periarticular  tissues  and  the  later  evident  involvement  of 
the  joint  itself  point  to  syphilis.  The  dactylitis  syphilitica  of  Liicke,  in 
the  tertiary  stage  of  syphilis,  mentioned  above  under  Chronic  Diseases 
of  the  Skin,  is  more  important.  One  or  more  joints  are  frequently 
involved  and  greatly  distended  but  painless;  the  skin  brownish- red ;  the 
folds  obliterated;  the  resistance  usually  exquisitely  elastic.  The  disease 
is  frequently  confined  to  the  capsule  of  the  joint;  exceptionally  the 
cartilage,  especially  in  the  more  central  portion,  is  transformed  into 
dense  connective  tissue,  the  chondritis  syphilitica  described  by  Virchow. 
Rarely  there  are  hyperplastic  changes  in  the  cartilage  and  synovialis,  or 
there  may  be  softening,  disintegration,  and  transformation  of  the  focus 
into  a  condition  similar  to  an  abscess  with  the  formation  of  fistulas. 

In  the  bones  simple  syphilitic  periostitis  is  most  frequent.  There  is 
a  peculiar  unilateral  nodular  formation  similar  to  the  "pseudotumeurs 
blanches"  of  the  joint,  or  there  are  circular  swellings  without  pain.  If 
they  are  not  recognized  as  syphilitic,  on  incising,  the  discharge  of 
tenacious,  clear,  gelatinous  masses  reveals  their  specific  nature;  the 
bone  may  be  intact.  Large  gummata  are  possible  in  the  bone  and 
medulla,  although  rare  in  the  metacarpals  and   the  fingers.     These 


350  DISEASES  OF  THE  WRIST  AND  HAND. 

growths  remain  limited  for  some  length  of  time  unless  complicated  by 
infection  from  without.  The  gumma  retrogrades  spontaneously  or  it 
may  involve  an  entire  phalanx,  the  latter  being  completely  absorbed. 

Treatment. — Conservative  treatment,  especially  renewed  inunctions, 
almost  always  brings  recovery,  as  the  patients  are  usually  otherwise  in 
excellent  condition.  Incision  and  cauterization  are  unnecessary.  If 
the  foci  have  perforated  to  the  surface  and  are  infected,  the  treatment 
is  the  same  as  for  the  other  bones  (skull,  tibia).  The  necrotic  masses, 
including  large  or  small  sequestra,  are  extirpated;  the  cavity  packed  and 
treated  as  a  septic  focus. 

Neuropathic  Arthritis. — The  arthropathy  of  nervous  origin  has 
recently  claimed  equally  the  interest  of  physicians  and  surgeons.  Tabes 
dorsalis  and  syringomyelia  are  the  chief  causes. 

Following  Mitchell  in  1831,  the  pathological  anatomy  and  clinical 
symptomatology  of  the  disease  have  been  especially  studied  by  Charcot 
and  v.  Bruns.  Interesting  observations  were  reported  by  Czerny  at  the 
Surgical  Congress  in  1886,  and  studies  were  made  by  Karg  under 
Thiersch.  The  part  played  by  syringomyelia  has  been  presented  in  a 
classical  manner  by  Fr.  Schultze.  The  nature  and  origin  of  neuropathic 
diseases  of  the  joint  are  still  obscure  at  the  present  time  in  spite  of 
numerous  hypotheses.  The  greater  frequency  of  syringomyelia  in  males 
explains  the  prevalence  of  arthropathy  in  the  same  sex.  The  first  symp- 
toms of  the  joint-involvement  were  recognized  in  4  cases  in  v.  Bruns' 
clinic  at  the  thirty-ninth,  thirty-seventh,  seventeenth,  and  ninth  year. 
In  51  joint-affections  collected  by  E.  Graf,  trauma  was  frequently  re- 
garded as  the  exciting  cause;  the  subsequent  swelling  was  usually  pain- 
less. A  certain  amount  of  appreciable  crepitus  in  the  deforming  joint 
was  the  first  intimation  to  the  patient  of  the  disease.  There  is  not 
necessarily  any  functional  loss.  The  diminution  or  loss  of  temperature- 
sense  is  recognizable  from  the  fact  that  fissures,  wounds,  inflammations, 
and  burns  occur  without  pain,  to  the  amazement  of  the  patient.  (See 
affections  of  the  skin  in  syringomyelia,  page  337.) 

In  spite  of  the  manifold  differences  in  the  local  symptoms  the  usually 
rapid  onset  of  the  deformity  is  characteristic.  The  enormous  swell- 
ing of  the  articular  surfaces,  with  or  without  moderate  effusion  in  the 
joint,  and  the  occasional  periarticular  swelling  of  the  soft  parts,  are 
very  striking;  also  the  tumefaction  of  the  capsule  with  irregular  deposits 
of  bone  and  the  crepitation  of  the  joint-surfaces  which  are  partly  de- 
nuded of  cartilage.  In  the  advanced  stages  the  synovial  sac  may  be  so 
relaxed  and  dilated  that  very  wide  abnormal  movement  is  possible, 
producing  looseness  and  separation  of  the  articular  surfaces  from  each 
other  and  unusual  subluxations.  Thickening  of  the  bone  in  some  spots 
is  accompanied  by  absorption  in  others.  In  the  differential  diagnosis 
the  point  given  by  v.  Volkmann  is  valuable,  namely,  that  whereas  in  the 
usual  arthritis  deformans  the  deforming  process  is  limited  to  the  joint, 
in  neuropathic  affections  of  central  origin  the  extra-articular  changes 
in  and  outside  of  the  capsule  are  so  dominant  that  they  can  scarcely 
escape  the  examiner.     In  spite  of  the  great  similarity  of  the  anatomical 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES  OF  THE  HAND.     351 

changes  in  the  arthropathy  of  tabes  and  syringomyelia,  the  deformation 
is  more  rapid  in  tabes,  as  emphasized  by  Sokoloff. 

In  regard  to  lepra  mutilans,  sec  page  337. 

Acromegaly.  —The  differential  diagnosis  requires  mention  of  acrome- 
galy, the  disturbance  in  growth  described  by  Friedreich  as  a  hyper- 
ostosis of  the  entire  skeleton,  and  by  Fritzsche  and  Klebs  as  a  non- 
congenital  hypertrophy.  The  slow  development  of  the  disease  is  usually 
completed  before  the  thirtieth  year;  the  gradual  enormous,  paw-like 
growth  of  the  hands  (and  feet)  extends  from  the  end-phalanges  to  the 
wrist  (ankles),  and  is  chiefly  due  to  hypertrophy  of  the  hone.  The  soft 
parts  are  not  necessarily  cedematous  or  glossy.  There  may  he  keloid 
growths  on  the  extremities.  The  condition  often  affects  only  single 
ringers,  and  may  thus  present  great  difficulty  in  the  differential  diag- 
nosis from  chronic  inflammation  of  the  bone  or  joint.  In  acromegaly, 
however,  the  joint  is  uninvolved.  There  are  almost  always  pathological 
changes  in  the  pituitary  body  and  the  procreative  glands,  sometimes 
in  the  thyroid  and  the  pancreas,  so  that  there  was  once  a  tendency  to 
deduce  the  physiological  connection  of  many  of  the  blood-producing 
glands  from  the  relationship  of  the  symptoms  of  the  presumably  corre- 
sponding diseases:  myxcedema,  cretinism,  Basedow's  disease.  For  this 
reason  v.  Bruns  has  exhibited  thyroidin  in  acromegaly,  apparently  with 
success.     There  is  no  surgical  treatment. 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES   OF  THE   HAND. 

Tuberculosis  of  the  Wrist-joint. — On  superficial  examination  a 
fungous  tuberculosis  of  the  tendon-sheaths  may  be  mistaken  for  dis- 
ease of  the  joint.  The  former  may  involve  the  joint  synovialis  and  this 
secondary  involvement  then  becomes  relatively  the  most  prominent. 
In  children  tuberculosis  of  the  wrist  is  relatively  infrequent  compared 
to  the  same  disease  of  the  ankle;  in  middle  and  advanced  life  disease 
of  the  hand  is  more  frequent.  In  the  latter  case  it  is  often  accompanied 
by  numerous  other  tuberculous  foci,  especially  in  the  lungs,  or  it  is  a 
local  manifestation  of  acute,  subacute,  or  chronic  miliary  tuberculosis. 

Symptoms. — The  symptoms  may  vary  greatly  according  to  the  severity 
of  the  attack:  from  a  serous  effusion  or  dry  caries  to  circumscribed  fun- 
gous growths  or  general  tuberculous  arthritis;  from  tenderness,  limited 
to  one  of  the  bones,  to  tenderness  of  the  infiltrated  soft  parts,  spongy 
swelling  of  a  spindle-shaped  "white  tumor"  of  the  wrist,  and  the  forma- 
tion of  one  or  more  fistulas;  from  the  latter  to  secondary  inoculation  of 
the  skin  with  the  development  of  lupus  or  ulcerating  tuberculosis  of  the 
skin  about  the  fistula.  In  the  history  trauma  plays  an  oft-repeated  role. 
The  localization,  in  the  strict  sense,  is  of  great  importance  for  the  deter- 
mination of  the  clinical  course  and  prognosis.  This  applies  particularly 
to  primary  osseous  tuberculosis  of  the  radius.  It  may  manifest  itself 
as  part  of  a  diffuse,  progressive  tuberculosis  of  the  shaft  (rare);  as  a 
wedge-shaped  focus  in  the  epiphysis;  as  a  rounded  focus  under  the 


352  DISEASES  OF  THE  WRIST  AND  HAND. 

cartilage.  Usually  some  time  elapses  before  the  radiocarpal  joint  is 
involved  from  the  erosion  of  the  cartilage;  the  mobility  of  the  joint  is 
fairly  normal,  the  thickening  and  tenderness  of  the  lower  end  of  the 
radius  pronounced,  suppuration  of  the  periosteum  and  involvement  of 
the  tendon-sheaths  usually  appearing  at  a  later  period.  Resection  gives 
excellent  results. 

Primary  tuberculosis  of  the  base  of  the  metacarpals  is  also  usually 
circumscribed,  the  second  and  third  being  most  frequently  affected. 

Tuberculosis  of  the  synovialis  and  of  the  carpal  bones  themselves 
represent  the  third  group,  in  the  strict  sense,  of  tuberculous  affections  of 
the  wrist-joint,  disease  of  the  synovialis  apparently  being  more  frequent. 

The  disease  is  liable  to  involve  the  whole  of  or  a  larger  part  of  the 
carpus,  although  one  occasionally  sees  only  one  or  more  bones  affected, 
especially  in  young  patients,  in  whom  recovery  follows  perforation, 
scraping,  or  partial  resection.  The  disease  here  therefore  gives  a  very 
bad  prognosis  not  only  as  to  function,  but  also  as  to  life  in  not  a  few 
instances.  It  is  often  seen  as  the  closing  act  of  a  tuberculous  cachexia 
following  phthisis;  still  even  in  such  doubtful  cases  the  author  has  not 
infrequently  seen  great  improvement  in  general  strength  follow  amputa- 
tion of  the  forearm.  The  " tuberculomas  juxta-synoviaux"  of  the  knee, 
described  by  Gangolphe,  and  of  the  wrist,  reported  by  Sabatier,  may 
be  interpreted  as  a  tuberculous  bursitis  or  as  a  localized,  circumscribed, 
tuberculous  process  connected  with  a  protrusion  of  the  synovialis  or  with 
the  tendon-sheaths.  Oilier  reported  a  localized  tuberculosis  from  a 
protrusion  of  the  synovialis  of  the  wrist. 

Diagnosis. — In  addition  to  the  history  (heredity)  and  general  condition 
(lungs)  the  diagnosis  of  tuberculosis  of  the  wrist  depends  essentially 
upon  the  following  points:  slowly  increasing  effusion  with  gradual  func- 
tional loss,  rarely  pronounced;  pain  in  the  bones,  soon  followed  by 
more  or  less  atrophy  of  the  muscles  of  the  forearm.  If  limited  to  a  cir- 
cumscribed focus,  there  is  localized  tenderness.  If  diffuse,  the  picture 
is  more  and  more  that  of  a  spindle-shaped  "white  swelling."  The 
boggy  oedema  of  the  skin  and  the  functional  impairment  of  the  tendons 
and  fingers  increase,  the  summit  of  the  inflammation  or  threatening 
perforation  being  indicated  by  a  reddish-blue  color  of  the  skin.  If  there 
are  fistulas  at  the  sides  of  the  extensors,  they  show  the  typical  tuberculous 
granulations,  soft,  oedematous,  coated,  and  necrotic.  The  diagnosis  is 
more  difficult  if  the  focus  is  localized  or  involves  a  portion  of  the  joint. 
The  differentiation  from  the  synovial  form  is  not  infrequently  dependent 
upon  incision.  Recently  the  .r-ray  has  made  surprising  revelations  even 
where  the  disease  was  limited  to  one  of  the  carpal  bones. 

Treatment. — The  treatment  depends  upon  the  age  and  general  con- 
dition of  the  patient,  and  the  location  and  extent  of  the  disease.  The 
prognosis  often  depends  largely  upon  the  general  condition.  Conser- 
vatism is  as  important  in  youth,  especially  in  childhood,  as  it  is  counter- 
indicated  in  advanced  life  and  by  a  generally  weakened  condition,  for 
in  the  latter  case  amputation  and  not  resection  is  to  be  considered. 
Statistics  are  useless  in  determining  the  demands  of  the  individual  case. 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES  OF  THE  11  AND.     353 


The  proper  decision  is  reached  in  each  case  by  a  sound  objective  analysis 
of  all  the  chances  under  consideration. 

In  the  conservative  treatment  the  chief  points  are  immobilization  of 
the  joint  and  general  hygiene  (diet,  care  of  the  skin,  air).  The  local 
measures  stimulating  the  growth  of  connective  tissue  and  attacking  the 
tuberculous  virus  are:  injection  of  antitubereulotis  substances  (iodoform 
emulsion,  usually  20  per  cent,  iodoform-glycerin  in  doses  of  grains  xv 
to  oj  of  iodoform,  injected  immediately  below  the  styloid  process  of  the 
radius  and  ulna  or  at  both  sides  of  the  extensor  tendons)  and  Bier's 
passive  congestion.  The  existence  of  a  sequestrum  counterindicates 
these  methods.  Aspiration  and  repeated  injection  of  cold  abscesses  give 
excellent  results,  granting  that  the  reactionary  power  of  the  organism  is 
good  (in  childhood)  or  at  least  sufficient  (in  the  absence  of  severe  general 
symptoms).  Osseous  foci  in  children  not  infrequently  heal  spontane- 
ously even  if  there  are  fistulas;  in  middle  life  it  is  better  to  scrape  them 
out  thoroughly  or  perform  an  arthreetomy.  Ankylosis  and  inflammatory 
subluxation  (volar  of  the  carpus)  may  recover  satisfactorily  under  con- 
servative treatment,  according  to  the  extent  of  the  process,  or,  on  the 
other  hand,  require  partial  resection  of  the  joint.  Even  if  the  surgery 
of  the  last  decade  has  carried  the  operative  treatment  of  tuberculous 
arthritis  too  far,  nevertheless  surgeons  are  indebted  to  Konig  for  having 
defined  the  operative  procedure  so  clearly  that  it  is  applicable  almost 
literally  to  the  wrrist  even  at  the  present  time.  The  principle  of  operative 
conservatism  is  perhaps  carried  too  far  by  many  to-day  to  the  detriment 
of  the  patient. 

Fig.  220.  Fig.  221. 


Spina  ventosa  of  the  first  and  third  metacarpals. 


Spina  ventosa  of  the  first  pha- 
lanx of  the  fourth  finger. 


It  must  be  admitted  that  the  conditions  are  often  very  unfavorable 
for  any  plan  of  operation.    The  various  anatomical  paths  through  which 
tuberculosis  can  spread  are  a  cross  for  the  radical  removal  of  all  diseased 
Vol.  III.— 23 


354 


DISEASES  OF  THE   WRIST  AND  HAND. 


tissue  and  are  the  cause  of  recurrence.  If,  however,  with  the  application 
of  the  Esmarch,  all  diseased  tissue  is  removed,  the  operation  is  aseptic, 
and  the  entire  after-treatment  formed  accordingly,  one  will  have  the 
satisfaction  of  seeing  how  recovery  can  follow  shrinkage  of  the  exuberant 
granulations  of  the  large  synovial  pockets  of  the  carpus.  If  possible, 
resection  should  be  limited  to  the  carpus  and  the  healthy  bones  of  the 
forearm  left  intact.  That  is  the  experience  of  Konig  and  many  others 
who  treat  accordingly. 

Fig.  222. 


Tuberculosis  of  the  second  phalanx  of  the  index   finger   (healed).     Ankylosis  of  the  interphalan- 
geal  joints  and  shortening  of  the  third  and  fourth  fingers  due  to  lupus,      (v.  Bruna.) 

Tuberculosis  of  the  Metacarpals  and  Fingers. — In  childhood  and 
youth  tuberculosis  most  frequently  affects  the  bones,  in  middle  and 
advanced  life  the  joints,  of  the  hand  and  fingers. 

Spina  ventosa  is  a  term  that  has  been  applied  for  a  long  while  (Wind- 
dorn)  to  a  characteristic  form  of  tuberculosis  of  the  bones.  It  often 
begins  at  the  epiphyseal  end  of  the  shaft,  spreads  in  a  relatively  short 
time  through  the  entire  medulla,  infiltrates  the  spongiosa,  and  replaces 
it  by  boggy,  purulent,  granulation-tissue  containing  the  sequestrated 
remnants  of  the  spongiosa.  The  thin  cortex  and  periosteum  are 
distended  by  the  increasing  inflammatory  products;  here  and  there 
the  periosteum  reacts  and  forms  new  bone,  so  that  soon  the  finger  looks 
as  if  the  bone  had  been  "blown  up."  The  result  of  the  process  is  well 
shown  by  the  x-ray.  The  disease  is  not  infrequently  found  simultaneously 
in  several  phalanges  or  metacarpals  in  the  same  hand.     (Fig.  220.) 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES  OF  THE  HAND.     355 

Symptoms. — The  cylindrical  swelling  of  the  bone  is  evidenced  by  a 
painless  (edematous  swelling  of  the  soft  parts  soon  followed  by  redness 
in  spots  or  all  over  the  area  involved.  The  function  of  the  tendons  is 
at  first  normal,  later  impaired  only  by  the  swelling.  'The  parts  feel 
elastic  and  may  later  show  softening  and  fluctuation.  In  the  meta- 
carpals the  lesion  may  be  mistaken  for  a  tendon-sheath  affection.  The 
picture  is  otherwise  so  characteristic  that  it  can  only  be  mistaken  for  a 
congenital  or  tertiary  syphilitic  lesion. 

Treatment.— In  the  early  stages  the  treatment  is  limited  to  general 
measures  of  hygiene  and  diet;  locally  to  immobilization.  .Many  cases 
of  spina  ventosa  recover  fully  under  this  treatment.     If  the  softening 

Fig.  '22\\. 


Arretted  growth  of  the  middle  finger  following  spina  ventosa  of   the  first   phalanx  in  the  third 

year  of  life. 


of  the  bone  extends  rapidly  and  fluctuating  abscesses  threaten  to  per- 
forate, the  diseased  medulla  should  be  removed.  To  avoid  the  tendons 
and  nerves,  the  incision  is  made  laterally  (on  the  metacarpus,  naturally 
on  the  dorsum).  All  diseased  tissue  is  carefully  removed  with  a  sharp 
spoon  and  the  wound  then  treated  in  general  principles.  The  result 
leaves  much  to  be  desired  from  an  aesthetic  point  of  view  in  all  cases  of 
extensive  involvement,  whether  in  the  metacarpus  or  phalanx.  Fre- 
quently high-grade  disturbances  of  growth  of  the  finger  follow,  almost 
comparable  to  total  defect.  (Fig.  223.)  In  this  case  one  finds  remnants  of 
an  epiphysis,  or  of  the  shaft  attached  to  the  next  joint,  and  in  between, 
fibrous  tissue  without  new  bone.     (Fig.  222.)     If  there  are  several  such 


356  DISEASES  OF  THE  WRIST  AND  HAND. 

changes  in  the  metacarpals  and  the  phalanges  in  the  same  hand,  the 
deformity  may  be  very  striking,  although  the  functional  impairment  in 
the  use  of  the  fingers  may  be  relatively  slight. 

Tuberculosis  of  the  Metacarpophalangeal  Joint. — Tuberculosis  of 
the  metacarpophalangeal  joint  either  starts  from  a  spina  yentosa  and 
extends  along  the  adjacent  bones  (in  children)  or  occurs  primarily  in 
the  synovialis  fin  old  age). 

Symptoms.  —  At  the  onset  the  characteristic  spindle-shaped  swelling 
and  a  serous  or  slightly  cloudy  effusion  are  the  dominant  features. 
Later  the  external  symptoms  of  inflammation  are  usually  spread  more 
diffusely  over  the  adjacent  parts,  or  the  case  may  first  be  seen  with  pro- 
nounced destruction  of  the  joint.  In  the  milder  form  there  is  slight 
crepitus  and  the  bones  are  moderately  displaceable  upon  each  other;  in 
the  severe  form  there  are  pronounced  displacement  of  the  adjacent  bony 
surfaces,  lateral  inflexion,  and  loosening  of  the  ligaments.  The  distal 
phalanges  may  pendulate  at  the  diseased  joints,  and,  if  chronic,  there 
may  be  perforation,  fistulas,  and  sequestra. 

Prognosis. — The  chances  of  recovery  without  operation  are  as  unfa- 
vorable in  these  small  joints  as  they  are  in  tuberculous  affections  of  the 
joint  in  middle  and  advanced  life. 

Treatment. — Usually  it  is  not  difficult  to  decide  between  arthreetomy, 
resection,  and  amputation.  Very  often  the  disease  is  accompanied  by 
an  advanced  pulmonary  tuberculosis. 


CONTRACTURES,1  ANKYLOSIS,  AND  DEFORMITIES  OF  THE  HAND. 

On  practical  grounds  it  is  advisable  to  consider  contractures  and 
ankylosis  together.  The  paralytic  and  neuropathic  forms  of  contrac- 
ture were  discussed  in  the  section  on  the  Upper  Arm  and  Forearm, 
because  the  source  lay  outside  of  the  hand,  and  because  they  are  more 
often  the  results  of  affections  and  lesions  at  a  higher  level.  The  de- 
formities in  lupus  causing  contractures  were  discussed  under  Tuber- 
culosis  of  the  Skin.  Helferich  was  the  first  to  call  attention  to  con- 
genital interphalangeal  ankylosis  of  the  thumb  in  ossifying  myositis. 
It  was  found  in  almost  three-fourths  of  the  cases  examined  for  that 
purpose.  Dermatogenic  and  tendogenic  contractures  are  important  on 
account  of  their  e  very-day  occurrence  and  unfortunate  functional  and 
aesthetic  consequences. 

Dermatogenic  Contractures. — Congenital  contracture  is  most  fre- 
quently ^fen  producing  flexion  of  the  little  finger  at  the  first  interpha- 
langeal joint.  The  skin  on  the  volar  side  is  too  short  to  allow  complete 
extension;  motion  is  free  in  the  joints.  Flexion  of  several  fingers,  the 
second  to  the  fifth,  has  also  been  reported  repeatedly.     In  all  of  these 

1  The  propriety  of  u-ing  the  English  equivalents  of  the  author's  dermntorjene,  lendngene,  etc..  in 
connection  with  'he  pathogene-i-  of  contracture-  seems  obvious  in  view  of  the  fact  that  myogenic, 
myogenous,  and  neurogenous  are  accepted  in  the  nomenclature  in  precisely  the  same  sen.-e. 


CONTRACTURES,  ANKYLOSIS  AND  DEFORMITIES  OF  WAND.    357 

forms  the  cause  is  to  be  found  in  a   primary  maldevelopmenl  of  the 

volar  skin. 

The  methods  of  1'.  Vbgt  and  llolfa  represent  the  fundamental  forms 
of  non-operative  treatment  of  such  contractures;  slight  modifications 
may  be  made.  Vbgt  connects  two  broad  rings  of  thin  sheet  metal 
(Fig.  221!,  for  the  first  and  middle  phalanges,  by  means  of  a  volar  strip 
hinged  at  the  level  of  the  joint;  extension  is  made  by  means  of  an  elastic 
hand  stretched  between  the  rings  on  the  extensor  surface.  Hoffa's 
apparatus  consists  of  a  springy,  well-padded  dorsal  splint  fastened  to 
the  finger  by  strips  of  adhesive  plaster  after  extend- 
ing the  finger  as  much  as  possible.  If  the  strip  is  not  Fig.  224. 
elastic  it  is  not  well  home  if  applied  with  force,  and 
is  useless  if  the  finger  is  not  extended.  The  skin 
may  be  incised  by  a  V-shaped  incision,  the  finger 
stretched,  and  the  edges  then  sutured  Y-shaped. 

Treatment.  —  Traumatic  contractures  following 
tears,  laceration,  inflammatory  destruction  of  the 
tissues,  or  burns,  are  all  to  he  regarded  and  treated 
from  the  same  point  of  view.  The  surgeon's  first 
task  should  be  to  prevent  their  development  as  much 

•1  1  rni  ii"  i-i  1  t.xtension  splint  for 

as  possiole.      the  prophylaxis  can  accomplish  much;    contractUre  of  the  fin- 
for  example,  by  applying  the  dressings  so  as  to  coun-    ger.    (Vogt.) 
teract  the   impending   contracture.      If    the  desired 
result  is  not  obtained  in  this  way,  active  massage  may  be  tried  or  finally 
incision,  transverse  and  longitudinal,  of  the  contracted  parts,  and  graft- 
ing to  prevent  secondary  changes  in  the  joint. 

If  the  treatment  is  not  effectual  or  the  contractures  come  under  obser- 
vation entirely  untreated,  the  surgeon  often  has  before  him  severe  hyper- 
flexion  and  extension  attitudes,  not  infrequently  with  abduction,  particu- 
larly after  burns.  The  functional  hindrance  is  caused  by  a  varying 
number  of  fibrous  bands  and  cicatricial  nodules,  covered  by  fragile, 
scaly,  friable  epidermis,  and  which  maintain  a  cartilaginous  firmness  in 
spite  of  massage.  The  hindrance  is  also  due  to  the  great  pain  caused 
by  the  attempts  at  stretching.  The  disuse  of  the  joint,  the  increased 
pressure  on  one  side  and  decreased  pressure  on  the  other  cause  corre- 
sponding atrophy  and  growths  in  the  occasionally  subluxated  joint- 
surfaces. 

In  many  cases,  especially  if  of  short  duration,  massage  and  gradual 
manual  and  mechanical  stretching  may  have  some  effect.  The  exten- 
sibility of  new  cicatricial  tissue,  which  sometimes  leads  to  annoying 
changes,  is  here  a  useful  quality.  W.  Busch  has  called  attention  to 
its  therapeutic  utility.  In  order  to  preserve  the  pliability  of  the  skin 
it  is  kept  constantly  greased  where  it  is  to  be  stretched.  It  should  be 
kneaded  and  stretched  daily  for  about  ten  minutes,  the  result  tested  by 
subsequent  passive  movements,  and  the  parts  then  held  in  the  position 
attained  if  it  does  not  discomfort  the  patient  too  much.  At  night  the 
parts  are  immobilized  in  a  spring  splint  such  as  was  described  above 
for  congenital  contracture.    Too  much,  however,  must  not  be  expected 


358  DISEASES  OF  THE   WRIST  AJSD  HAND. 

from  these  manipulations,  particularly  if  the  cicatrix  is  old  and  the 

patient  advanced  in  years.  In  any  event  they  are  always  a  test  of  the 
endurance  of  the  surgeon  and  patient.  Of  the  large  number  of  apparatus 
constructed  and  recommended,  tho.-^e  of  Delacroix,  Eulenburg,  Nyrop, 
Matthieu,  and  Schonborn  have  enjoyed  the  greatest  approval.  The 
one  of  Schonborn  Fig.  '!-'<  serves  as  a  model  for  general  use;  a 
leather  sheath  like  a  glove  {A  I  supports  a  metal  dorsal  splint  (B  B)  and 
rear-lies  to  the  distal  third  of  the  first  phalanx  of  the  finger  or  finders 
involved;  it  is  connected  at  this  point  by  two  lateral  hinge-joints  to  a 
metal  gutter-splint  I):  this  gutter  is  pulled  toward  the  dorsal  splint  by 
elastic  bands  and  so  exerts  traction  on  the  contracture.  Stretching  by 
a  suspended  weight  deserves  trial.  In  the  medico-mechanical  institutes 
Krukenberg's  or  similar  apparatus  is  used. 

Fig.  225. 


Schonborn's  correcting  splint  for  contracture  of  the  finger. 

In  many,  in  fact  in  all,  severe  and  extensive  cases,  especially  those 
due  to  burns,  these  measures  do  not  accomplish  tlifj  desired  result  even 
after  long  use.  This  applies  particularly  to  old  cicatrices.  In  operat- 
ing it  is  advisable  not  to  limit  one's  self  to  one  method.  In  some  cases 
an  oblique  incision  and  shifting  the  edges  upon  each  other  are  successful ; 
in  others  a  V-incision,  or  excision  and  Thiersch  grafts,  or  pedunculated 
or  whole-skin  flaps.  Whatever  method  is  used,  the  essential  is  to  prevent 
the  return  of  the  contracture  by  overstretching,  applying  an  excess  <r 
skin,  and  maintaining  the  overstretehing  by  the  splint.  After  operation 
orthopaedic  measures  are  necessary  for  a  long  time.  The  result  does 
not  always  lie  in  the  surgeon's  hands;  even  the  greatest  care  in  all  the 
details  of  the  operation  and  after-treatment  is  sometimes  followed  by 
even  greater  shrinkage  and  the  patients  are  no  better  off  than  before. 
The  reply  to  the  question  why,  lies  in  the  physiological  difference  of 
ilit-  cicatrix  in  different  individuals,  an  extremely  interesting  chapter 
of  surgical  physiology  and  pathology,  which,  however,  cannot  be  fol- 
lower! here. 

Tendogenic  and  Myogenic  Contractures. — In  tendinous  contrac- 
tures the  surgeon  has  to  distinguish  as  to  whether  the  cause  is  adhe- 


CONTRACTURES,  ANKYLOSIS  AND  DEFORMITIES  OF  HAND.    359 

sdon  between  the  tendon  and  its  sheath,  or  shortening  by  retraction, 
or  a  defect  in  the  tendon,  or  paralysis  or  division  of  the  aerv<  -  of  the 
antagonistic  muscles.  The  prognosis  <»t"  the  first  group  (gonorrhoea] 
and  traumatic  origin)  is  usually  favorable,  bul  of  those  due  to  phleg- 
monous destruction  and  loss  of  a  portion  of  the  tendon  it  is  very  unfa- 
vorable, [ncised  wounds  of  the  tendons  and  the  subsequent  contracture 
due  to  shortening  of  the  antagonistic  muscles  represent  a  very  grateful 
field  of  surgery;  the  same  applies  to  operations  for  division  of  the  nerves, 
if  not  performed  too  long  after  the  injury,  at  the  latest  within  one  and 
line-half  years. 

The  shortening  occurring  in  a  sound  tendon  following  division  of  the 
antagonistic  muscle  is  suitable  for  plastic  operation  even  years  after  the 
injury.  In  general,  the  greater  the  diameter  of  the  stumps,  the  better 
the  chances  of  success;  therefore  the  tendons  in  the  finger  are  not  very 
favorable  for  plastic  operation.  The  defects  following  phlegmonous 
destruction  constitute  the  most  doubtful  contingent.  In  this  case  the 
surgeon  has  to  deal  not  only  with  stumps  at  unequal  distances  from 
each  other,  but  also  usually  with  those  that  are  widely  retracted  and 
held  by  cicatrices.  The  wound  is  covered  in  by  tense,  shrunken, 
poorly  nourished  skin.  The  tendon  can  be  reunited  by  a  plastic  opera- 
tion and  the  wound  covered  in  by  a  skin-flap,  but  the  functional 
result  is  usually  incomplete.  For  a  laboring-man  the  author  recom- 
mends exarticulation  of  the  contractured  section  of  the  finger  or  of 
the  whole  finger.  If  removal  at  the  first  phalanx  is  indicated  in  the 
case  of  the  third  or  the  fourth  finger,  the  author  usually  employs  Adel- 
mann's  amputation  at  the  neck  of  the  metacarpus,  which  allows  the 
hand  to  be  closed  much  better.  (See  also  above  in  reference  to  the 
results  of  panaritia  and  phlegmon  of  the  tendon-sheath>.  I 

Shortening  of  the  muscles  ( myogenic  contracture)  by  retracting  the 
tendons  naturally  causes  contracture  of  the  fingers.  Besides  resulting 
from  central  and  peripheral  nerve  affections,  the  condition  may  also  follow 
prolonged  immobilization  of  the  arm  and  hand.  The  action  of  the  flexors 
soon  predominates  and  leads  more  and  more  to  a  flexion  contracture. 
The  highest  grade  follows  ischemic  degeneration  of  the  muscles,  as  pro- 
duced by  constricting  dressings.  (See  page  317.)  In  the  latter  case  sur- 
gical treatment  is  almost  powerless.  The  myogenic  contractures  due  to 
immobilization  are  overcome  in  weeks  or  months  by  use,  massage,  exer- 
cises, electricity,  and  baths.  So  the  prophylaxis  is  of  first  importance: 
to  guard  against  protracted  immobilization  in  splints.  The  contrac- 
tures due  to  suppuration  and  cicatricial  contraction  of  the  muscles  occa- 
sionally yield  only  to  tenotomy,  or,  better,  remain  a  noli  mc  tangere 
against  further  treatment. 

Arthrogenic  Contractures. — Two  main  varieties  may  be  distin- 
guished: those  in  which  the  hindrance  is  in  the  joint,  fibrous  or  bony 
ankylosis  or  shrinkage  of  the  capsule;  and  those  in  which  the  hindrance 
is  extra -articular.  Accurately  speaking,  only  the  former  are  purely  arthro- 
genic. As  mentioned,  they  are  usually  the  result  of  acute  and  chronic 
inflammations,  pyogenic  or  otherwise  infectious.    The  ankylosis  is  <\ue  to 


360  DISEASES  OF  THE   WRIST  AND  HAND. 

alterations  in  the  cartilage  following  protracted  changes  in  the  circula- 
tion, and  on  account  of  the  slight  tendency  of  the  cartilage  to  regener- 
ate, the  contractures  occasioned  by  such  ankylosis — which  ankylosis 
is  more  essentially  a  contracture,  although  termed  ankylosis — are  only 
amenable  to  resection  or  exarticulation.  Massage  and  passive  motion 
are  useless.  Not  infrequently  as  the  result  of  failure  to  recognize  the 
anatomical  condition,  severe  pain  is  added  to  the  injury  by  employing 
forced  movements.  The  author  cannot  suppress  the  fact  that  this 
happens  repeatedly  in  medico-mechanical  institutes.  Treatment  In- 
passive  movements  and  massage  are  only  indicated  when  the  apparent 
ankylosis  of  the  joint  is  due  exclusively  to  shrinkage  of  the  capsule. 

The  same  applies  to  the  class  of  so-called  arthrogenic  contractures 
which  are  due  to  periarticular  adhesions  of  the  tendons  and  adhesions 
along  the  tendons.  Incision  is  rarely  necessary,  and  recovery  is  usually 
effected  within  a  few  weeks  by  massage  and  movements. 

Lateral  displacement  of  the  tendons  should  be  mentioned  in  connection 
with  arthrogenic  contractures,  as  it  is  not  infrequently  associated  with 
deforming  arthritis  and  acts  as  an  extra-articular  cause  of  contracture. 
Described  by  Charcot,  its  mechanism  and  treatment  were  first  carefully 
studied  by  Krukenberg.  The  hand  is  adducted  and  presents  a  flexion 
contracture  in  the  metacarpophalangeal  joints,  greatest  in  the  fifth,  less 
in  the  fourth,  third,  and  second,  the  thumb  being  uninvolved.  The 
fingers  may  be  extended  in  the  other — interphalangeal — joints  and  pro- 
duce a  rather  characteristic  deformity.  On  palpation  the  metacarpal 
heads  of  the  contracted  fingers  are  prominent  and  the  extensor  tendons 
are  displaced  to  the  ulnar  side  of  the  shallow  dorsal  groove  on  the  head 
of  the  metacarpals.  It  appears  doubtful  whether  one  may  expect  to 
be  successful  in  following  Krukenberg's  proposal  to  replace  the  tendons 
by  chiselling  out  the  old  groove  or  making  a  new  one  on  the  head  of 
the  metacarpal.     So  far  the  author  has  hesitated  to  try  it. 

Spastic  Contractures. — The  spastic  contractures  of  the  fingers, 
although  they  do  not  belong  in  the  strict  sense  among  contractures, 
are  best  introduced  at  this  point.  They  occur  as  occupational  diseases 
in  individuals  who  do  uninterrupted,  exacting  work  with  the  fingers 
for  many  hours  each  day:  writers,  pianists,  violinists.  The  most  fre- 
quent of  these  co-ordinated  occupation-neuroses  is  "writers'  cramp." 
Its  clinical  picture  varies  according  as  the  paralytic  or  pronounced 
spastic  symptoms  predominate.  Benedict  very  aptly  divides  them  into 
paralytic,  spastic,  and  convulsive.  In  the  first  of  these  there  is  chiefly  a 
rapidly  increasing  tired  feeling  in  the  arm  and  hand.  In  the  second 
there  are  tonic  and  clonic  spasms,  especially  spastic  contraction  of  the 
thumb  against  the  palm.  In  the  third  there  is  a  tremor  beginning  with 
the  writing  and  by  its  gradual  increase  preventing  the  necessary  co- 
ordinated movements.  In  these  occupation-neuroses  the  cramp  begins 
as  soon  as  the  special  work  is  attempted,  whereas  it  often  remains  absent 
in  other  similar  complicated  actions.  This  would  indicate  that  the 
treatment  should  begin  with  temporary  or  complete  interruption  of 
the  work.     Unfortunately,  however,  there  is  a  large  number  of  cases 


COSTllACTrilES,  ANKYLOSIS  AND  DEFORMITIES  OF  HAND.     36] 

in  which  it  returns  just  as  soon  as  the  old  occupation  is  resumed.  The 
prognosis  is  therefore  generally  to  be  given  as  unfavorable. 

Treatment. — The  treatment  consists  chiefly  in  strengthening  or  rest- 
ing the  muscles  involved  in  the  cramp  and  applying  massage  over  the 
muscles  and  their  corresponding  nerves.  It  is  profitable  to  stroke  with 
varying  duration  and  intensity  the  muscles  of  the  mid-hand  (lumbricales 

and  interossei),  those  of  the  forearm,  upper  arm,  and  shoulder;  the 
cervical  and  brachial  plexus,  the  ulnar,  radial,  and  median  nerves, 
stroking  the  muscles  upward,  the  nerves  downward.  Galvanism  is 
best  applied  with  the  positive  pole  at  the  neck  and  the  negative  pole  in 
the  supraclavicular  fossa  or  at  selected  points  along  the  nerves  of  the 
arm.  The  application  should  be  increased  from  two  gradually  up  to 
six  or  eight  minutes.  After  several  months  there  may  be  improvement, 
in  mild  cases  recovery.  In  every  case  there  is  the  danger  of  recurrence 
on  resuming  the  former  injurious  occupation.  Many  apparatus  exist 
devised  for  the  purpose  of  "cutting-out"  the  affected  muscles.  Accord- 
ingly they  "harness"  the  hand  to  a  certain  extent  and  spare  the  fingers 
from  the  combined  action  of  the  individual  muscles  and  simplify  the 
movements  by  shifting  them  to  the  wrist.  Nussbaum's  well-known 
bracelet  usually  tires  the  hand  very  much  in  the  long  run.  To  the 
author's  mind  the  same  applies  to  Zabludowsky's  small  apparatus.  It 
is  well  to  try  various  apparatus  on  the  same  patient. 

Dupuytren's  Contracture  of  the  Fingers.— Surgeons  are  indebted  to 
Dupuytren  for  the  first  accurate  anatomical  description  of  contraction 
of  the  palmar  fascia.  In  opposition  to  Boyer  and  Cooper,  he  showed 
that  the  characteristic  cord-like  contraction  of  the  finger  was  due  to 
gradual  shortening  of  the  palmar  aponeurosis.  New  fibrous  tissue  and 
shrinkage  predominate  in  the  microscopical  picture.  The  new-forma- 
tion is  doubtless  of  an  inflammatory  nature  and  appears  in  spots. 
Nuclear  proliferation  takes  place  in  the  sheaths  of  the  arteries  as  well 
as  in  the  connective  tissue  between  the  individual  fibrous  bands.  This 
nuclear  proliferation  is  beautifully  shown  in  the  fibres  attached  to  the 
skin.  (Langhans.)  The  contracture  attitude  of  the  fingers  is  caused  by 
the  shrinkage  of  the  bands  of  the  palmar  aponeurosis  running  to  the 
fingers  and  merging  into  the  tendon-sheaths  at  both  sides  of  each  finger. 
The  aponeurosis  also  sends  compact  fibres  into  the  subcutis.  On  expos- 
ing the  radiations  of  the  aponeurosis  in  the  fingers  the  author  frequently 
finds  considerable  growth,  similar  to  a  fibroma,  palpable  beneath  the 
skin  as  circumscribed  nodules. 

The  cause  of  origin  of  these  changes  is  the  irritation  of  the  tissues 
produced  by  hard  work  and  trauma;  the  coexistence  of  arthritis  and 
contraction  of  the  palmar  aponeurosis  has  been  noted  at  various  times. 
(Konig,  Liicke.)  Many  authors  regard  the  disappearance  of  the  fat- 
cushion  in  advanced  age  as  predisposing.  Recently  the  etiology  of  the 
contracture  has  again  been  actively  discussed.  Ledderhose,  from  clinical 
observation  and  microscopical  study,  is  convinced  that  the  beginning  of 
the  disease  is  an  inflammatory  proliferative  process  in  the  cells  and 
vessels  of  the  aponeurosis,  a  "fasciitis,"  and  that  later  trauma  produces 


362 


DISEASES  OF  THE   WRIST  AND  HAND. 


lesions  in  the  inflamed  and  changed  fascia  and  leads  to  the  formation 
of  nodules,  and  through  these  to  retraction  of  the  tissues.  Janssen 
completely  excludes  the  causal  significance  of  trauma.  Neutra  seems 
to  have  gotten  especially  far  away  from  an  objective  view  in  con- 
necting the  contraction  with  diseases  of  the  central  nervous  system. 
The  author  has  never  seen  the  disease  in  females,  and  it  has  never  been 
seen  in  children.  In  2  of  the  author's  cases,  father  and  son,  the  father 
had  the  maximal  contracture  position;  the  son,  a  lawyer,  thirty-three 
years  old,  had  a  unilateral  deformity. 


Fig.  226. 


Fig.  227. 


Different  stages  of-  Dupuytren's  contracture  of  the  fingers. 


The  affection  usually  begins  at  the  metacarpophalangeal  joint  of  the 
fifth  or  fourth  finger,  or  somewhat  more  distally;  then  attacks  the  third 
finger,  the  thumb,  and  leaves  the  index  finger  free  the  longest.  Generally 
one  or  two  years  pass  after  the  appearance  of  the  first  nodular  thickening 
before  the  contracture  begins,  and  in  six,  ten,  or  twelve  years  it  has 
reached  a  high  grade,  the  highest  being  when  the  finger-nails  cut  into 
the  palm.  At  the  onset  it  is  usually  painless.  Flexion  is  unimpaired, 
whereas  extension  beyond  the  contracture  position  is  painful  and  well- 
nigh  impossible.  The  diagnosis  is  simple.  The  characteristic  localiza- 
tion, together  with  the  pronounced  formation  of  nodules  or  bands  without 
cicatricial  changes  in  the  skin,  and  the  lack  of  inflammatory  symptoms, 
are  easily  interpreted. 


CONTRACTURES,  A\KYL0SIS  AND  DEFORMITIES  OF  BAND,     ;;<;;; 

Treatment. — At  the  onset  treatment  by  apparatus,  massage,  and  baths 

may  check  the  process.  In  advanced  cases  operation  is  Indicated, 
namely,  thorough  excision  of  the  diseased  parts  of  the  aponeurosis.    The 

author  advises  excision  even  at  the  outset,  as  it  can  he  performed  without 
harm  if  aseptic,  insures  the  quickest  result,  and  if  there  is  a  good,  yield- 
ing cicatrix  without  any  loss  of  skin,  brings  recovery.  The  author  makes 
the  incision  entirely  from  an  anatomical  point  of  view  and  dependent 
upon  the  extent  of  the  disease;  in  every  case  he  makes  a  large  palmar 
flap  with  a  lateral  base.  Lotheissen  has  published  an  article  on  a  similar 
incision.  Lexer  recommends  even  for  milder  cases  that  in  addition  to 
removing  the  entire  aponeurosis  large  portions  of  skin  or  the  entire 
palmar  skin  should  he  sacrificed,  and  covers  the  wound  with  a  whole- 
skin  flap,  a  more  extensive  operation.  The  results  are  designated  as 
good  "in  every  case  in  proportion  to  the  extent  of  the  operation." 
Older  operations  are  omitted  because  they  take  our  present  knowledge 
of  the  pathology  only  partially  into  account. 

Snapping  Finger.  —  In  describing  contractures,  u  snapping  finger" 
(Trigger  finger,  Schnellender  finger,  doigt  a  ressort)  should  be  consid- 
ered, the  etiology  of  which  has  not  been  cleared  up  in  every  ease.  The 
peculiarity  of  the  affection  is  that  in  flexing  and  extending  the  finger, 
occasionally  only  during  one  of  these  movements,  there  is  a  sudden 
cheeking,  ahvays  at  the  same  point,  usually  with  a  slightly  painful  jerk. 
The  patients  then  have  to  exert  some  force  to  free  the  finger;  sometimes 
they  have  to  loosen  it  with  the  other  hand;  its  liberation  may  also  be 
accompanied  by  a  snap. 

Since  the  first  report  made  by  Notta,  in  1850,  the  affection  has  con- 
stantly claimed  the  attention  of  surgeons,  and  numerous  hypotheses 
have  been  advanced  as  to  its  pathogenesis.  Schonborn's  operations 
and  various  autopsies  threw  the  first  light  upon  the  subject.  Robel 
collected  161  cases  for  the  author,  only  a  few  of  which  did  not  involve 
the  fingers;  41  were  in  the  thumb,  and  of  these  28  in  the  right;  12  in  the 
index  finger,  of  these  11  in  the  right;  47  in  the  middle  finger,  of  these 
34  in  the  right;  44  in  the  ring  finger,  of  these  21  in  the  right;  10  in  the 
little  finger  with  5  in  the  right.  The  sexes  were  equally  represented. 
In  131  cases,  93  were  given  as  the  result  of  trauma  or  overwork.  In 
addition  to  experimental  investigations  of  Menzel,  A.  Schmitt,  Poirier, 
and  others;  there  have  been  so  far  26  examinations  made  on  operation  or 
autopsy  Lannelongue  found  a  tumor,  bean-size,  of  the  tendon-sheath 
over  the  base  of  the  first  phalanx  of  the  afTected  finger.  Leisrinck  found 
a  hernial  protrusion  of  synovial  membrane.  Wiesinger  found  that  a 
tender  nodule  was  due  to  a  yellowish  thickening  of  the  tendon,  h  inch 
long,  which  caught  in  the  sheath,  and  was  released  with  a  snap.  Sehon- 
born  reports  a  transverse  band  over  the  flexor  tendon  at  the  first  inter- 
phalangeal  joint  of  the  middle  finger,  and  on  incising  exposed  a  trans- 
verse fibrous  band  passing  over  both  tendons,  which  at  this  point  had  no 
sheath.  There  was  also  a  fibrinous  deposit  on  the  flexor  sublimis 
tendon.  In  a  boy  two  and  one-half  years  old,  Sick  saw  the  affection 
develop  within  eight  weeks  after  a   puncture- wound ;    the  operation 


364  DISEASES  OF  THE  WRIST  AND  HAND. 

showed  that  puncture  had  nicked  off  a  tab  of  the  tendon  which  turned 
back  and  caught,  during  flexion,  in  the  sheath.  Duplay  found  an 
annular  fibrous  thickening  of  the  tendon  sheath;  v.  Heineke  found  a  simi- 
lar thickening  due  to  previous  inflammation.  The  author's  second  case 
admitted  of  no  other  interpretation.  The  findings  on  autopsy  reported 
by  Necker  from  v.  Brims'  clinic,  in  the  case  of  a  woman  fifty-two  years  old, 
with  the  affection  in  both  middle  fingers  at  the  first  interphalangeal 
joints,  are  especially  interesting:  In  the  right  finger  there  was  a  hard 
spindle-shaped  thickening  of  the  tendon,  f  inch  long  and  double  the 
width  of  the  tendon,  just  below  the  forking  of  the  flexor  sublimis;  the 
palmar  surface  of  the  swelling  was  arched,  the  dorsal  surface,  lying  upon 
the  profundus  tendon,  flat;  on  dividing  the  sublimis  tendons  below  and 
exposing  the  profundus  tendon  a  similar  thickening  was  found  arched 
in  opposite  direction.  The  condition  was  the  same  in  the  left  finger. 
Microscopically  the  fasciculi  of  the  tendons  were  found  separated  by 
undulating  hypertrophied  connective  tissue,  here  and  there  containing 
bloodvessels,  the  fibrils  being  thicker  and  more  compactly  arranged 
than  in  normal  interfascicular  connective  tissue.  Baumgarten  regarded 
the-  process  as  a  simple  hypertrophy  of  connective  tissue.  Similar 
microscopical  conditions  were  found  in  the  author's  first  traumatic  case 
operated  on,  and  reported  in  detail  in  Robel's  inaugural  dissertation. 
In  fourteen  cases  in  soldiers  (Schulte)  the  affection  was  referred  to  rifle 
drill  at  the  beginning  of  service.  In  all  cases  it  began  with  stiffness,  and 
thickening  of  the  flexor  tendon  was  demonstrable  at  an  early  period; 
the  "snapping"  took  place  only  during  extension.  Nelaton  regarded 
thickening  of  the  synovial  membrane  of  the  joint  as  the  principal  cause; 
Menzel,  and  with  him  Hyrtl,  Berger,  Vogt,  Fieber,  Felicki,  believe  that 
it  is  caused  by  a  nodular  thickening  of  the  tendon  and  simultaneous  con- 
striction of  the  sheath.  The  single  instances  which  showed  no  analogous 
condition,  especially  those  explained  by  the  theory  of  abnormally  high 
tension  and  sudden  relaxation  of  the  ligaments  (Poirier),  displacement 
of  the  ligamentous  insertions  (Steinthal),  enlargement  of  the  transverse 
articular  ridges  or  lateral  protuberances  from  the  articular  head  (Konig, 
Vogt),  and  finally  those  explained  by  Carlier's  theory  of  nervous  dis- 
position and  reflex  spasm  of  the  flexors — all  these  are  individual  observa- 
tions which  cannot  be  classified  with  the  great  majority  of  cases.  Based 
on  the  fact  that  most  of  the  operations  and  autopsies  supported  Menzel's 
original  theory,  the  author  is  inclined  to  the  view  that  the  snapping  is 
chiefly  caused  by  a  "tendinitis  callosa  circumscripta"  or  "nodosa  hyper- 
plastica,"  often  traumatic.  Perhaps  Ziegler's  view  is  correct,  that  the 
swelling  of  the  tendon  is  due  to  the  irritation  of  urate  deposits,  for  Bar- 
low, Relm,  Troisier,  and  others  have  also  mentioned  rheumatic  nodules 
in  this  connection.  There  is  little  accurate  microscopical  evidence  for 
regarding  the  thickening  as  a  genuine  fibroma.  Vogt  claimed  that  an 
interstitial  extravasation  of  blood  in  the  tendon  might  be  significant 
etiologically. 

Certainly  a  small  chondrosarcoma  (Schmitt)  or  tuberculosis  or  gumma 
are  rare  causes. 


TUMORS  OF   THE  HAND  AND  FINGERS.  ;;<;;, 

Treatment. — In  recent  cases  massage  may  occasionally  be  successful 
(Schulte);  in  old  eases  its  efficacy  is  improbable.  For  the  latter,  opera- 
tion offers  the  best  prospects,  the  extent  of  the  attack  depending  on  the 

condition  found.  Operation  is  almost  always  followed  by  recovery. 
In  the  author's  cases  it  was  demonstrated  as  permanent  at  the  end  of  a 
year. 

TUMORS  OF  THE   HAND  AND  FINGERS. 

Ganglion. — Ganglion  is  described  here  partly  on  clinical  and  prac- 
tical, partly  on  etiological  grounds.  Following  the  earlier  investigations 
of  Gosselin,  in  1852,  and  of  Teichmann,  in  1856,  it  was  customary  to 
regard  the  small  cysts  found  about  the  wrist  containing  a  gelatinous 
substance  and  covered  with  a  dense  fibrous  sheath  as  protrusions— 
diverticula — of  the  synovialis  of  the  joint,  the  pedicle  of  which  com- 
municating with  the  joint  having  become  obliterated  by  adhesive  inflam- 
matory processes  so  that  they  became  closed  off  and  appeared  as  inde- 
pendent cysts  near  the  joint.  Ganglion  thus  came  to  be  regarded  as  a 
retention-cyst  in  which  the  collected  synovial  fluid  thickened  and  became 
gelatinous,  v.  Volkmann  sided  with  this  explanation,  but  for  the  origin 
of  the  form  of  ganglion  known  as  colloid  cyst  of  the  joint  admitted  the 
explanation  given  by  Virchow,  namely,  that  originally  small  multi- 
locular  cysts  were  formed  out  of  small  spaces  in  the  loose  cellular  tissue 
about  the  tendons,  and  later  developed  into  a  ganglion  through  dis- 
appearance of  the  individual  dividing  septa.  Based  upon  his  operations, 
Riedel  defined  the  pathogenesis  more  sharply:  on  excising  a  ganglion 
broadly  attached  to  the  capsule  of  the  joint,  if  the  dissection  is  done 
carefully,  the  capsule  often  shows  a  defect  before  the  ganglion  is  opened. 
This  shows  that  only  a  very  thin  septum  exists  between  the  ganglion 
and  the  cavity  of  the  joint.  Where  the  pedicle  was  very  short,  on 
cutting  it  off,  gelatinous  material  came  from  the  ganglion  and  synovial 
fluid  from  the  joint.  It  follows  that  the  ganglion  can  be  produced  only 
within  the  substance  of  the  joint-capsule. 

These  considerations  of  Riedel  have  been  fully  confirmed  by  the 
studies  of  Ledderhose,  and  his  in  turn  by  other  authors.  Accordingly, 
in  ganglion  the  surgeon  is  supposed  to  have  before  him  a  "cystoma" 
resulting  from  colloid  degeneration  of  the  connective  tissue.  If  these 
changes  in  the  connective  tissue  occur  at  several  adjacent  points,  the 
ganglia  formed  are  multilocular;  the  septa  between  the  various  compart- 
ments disappear  gradually  and  form  the  unilocular  ganglion.  According 
to  this,  the  significance  of  the  contents  as  products  of  exudation  and  the 
conception  of  retention  cysts  would  be  invalid.  Payr  places  their  trau- 
matic origin  in  the  foregound  and  regards  them  as  traumatic  inflamma- 
tory  softening  cysts.  Konig  maintains  that  the  ganglia  "  are  related  to  the 
capsule."  He  agrees  with  Falkson  that  the  ganglia  are  usually  adherent 
to  the  tendon-sheaths,  but  that  the  tumors  extended  to  the  capsule  in 
all  cases  and  had  to  be  dissected  off,  so  that  their  origin  from  the  capsule 
is  more  likely,  the  adhesion  to  the  tendon-sheaths  being  secondary. 


366  DISEASES  <>F  THE  WRIST  AND  HAND. 

On  the  hand,  the  ganglion  is  found  chiefly  on  the  radial  side  of  the 
back  of  the  wrist-joint,  especially  between  the  tendons  of  the  exti 
indicis  and  the  extensor  carpi  radialis.  Much  less  frequently  it  lies 
to  the  volar  ,-ide  of  the  epiphysis  of  the  radius  and  causes  severe  func- 
tional disturbance,  according  to  Konig  especially  in  pianists.  Maison- 
neuve,  Verneuil.  and  Witzel  have  reported  small,  hard  cysts  covered 
with  endothelium  attached  to  the  capsule  or  the  periosteum  and  situated 
upon  the  flexors  in  the  palm — metacarpophalangeal  joint — or  upon  the 
flexor  surface  of  the  first  phalanges,  and  causing  neuralgia  in  the  nerves 
of  the  fingers  by  their  pressure.  Ganglioo  is  seen  more  frequently  in 
women  than  in  men.  and  is  more  common  in  youth. 

The  form  of  the  typical  ganglion  upon  the  dorsum  is  usually  spherical, 
sionally  tabulated,  the  upper  surface  smooth,  the  contents  fluctu- 
ating. The  tumor  becomes  flattened  when  the  wrist  is  flexed;  the  dense 
lie  appears  to  relax  and  previously  uncertain  fluctuation  becomes 
distinct.  It  rarely  attains  to  greater  -ize  than  that  of  a  hazelnut.  It.-, 
mobility  is  often  evident.  The  functional  disturbance  is  usually  slight. 
Hysterical   _  onetimes  complain  of   a  weakening  sensation  caused 

by  it.     Traumatic  origin,  though  often  stated,  is  rarely  credible  and  is 
illy  absent. 

Treatment. — In  view  of  the  infection  of  the  tendon-sheaths  or  joint 
expected  at  an  earlier  period,  the  treatment  had  every  reason  to 
be  hesitating.  The  contents  of  the  sac  were  usuallv  crushed  foreiblv 
with  the  thumb  or  by  a  blow  of  a  hammer,  or  liberated  by  subcutaneous 
discission  with  an  instrument  similar  to  a  tenotome.  The  results  of 
all  these  methods  are  very  uncertain,  recurrence  usually  follows.  Aspi- 
ration of  the  contents  and  injection  of  iodine  are  equally  uncertain. 
Splitting  the  ganglion  and  packing  under  aseptic  precautions  gives 
better  results,  the  packing  if  continued  long  enough  producing  obliter- 
ation of  the  sac.  Extirpation,  however,  is  the  most  certain  method  and 
the  one  most  used  at  the  present  time,  but  requires  careful  asepsis. 
With  the  aid  of  the  Esmarch  it  is  easily  accomplished:  if  large  openings 
are  made  into  the  joint,  they  are  closed  with  from  one  to  three  buried 
silk  sutures;  -light  injuries  of  the  tendon-sheaths  may  be  ignored. 
The  skin  suture  should  be  exact.  Recovery  follows  in  from  five  to 
-    inder  an  aseptic  dres-ing  upon  a  hand  splint. 

I  >:  :he  genuine  tumors  of  the  hand  the  first  to  be  considered  are  warts, 
naevi,  angioma,  epithelial  cysts,  and  the  rare  lipoma  of  the  skin.  The 
hand  is  a  -pot  of  predilection  for  enchondroma:  osteoma  is  sup 
to  be  more  rare.  Of  the  malignant  tumors  the  author  will  consider 
ima  of  the  fascia,  tendon-sheaths,  periosteum,  or  bone,  and  epithelial 
carcinoma.  According  to  the  careful  compilation  of  hi-  assistant.  Dr. 
Holler,  of  the  36  tumors  of  the  hand  and  fingers  occurring  among 
36,144  patients  in  the  author's  polyclinic,  there  were  10  fibromata. 
7  -arcomata.  7  epithelial  cysts,  ■">  angiomata,  4  carcinomata.  2  o>teomata, 
1  neuroma,  no  enchondromata.  Naevi,  papilloma,  and  ganglia  are 
omitted.    Al>o  from  the  statistics  of  Guilt  and  R.  Miiller  the  frequency 


TUMORS  OF  THE  11AM)  AM)  FINGERS.  367 

of  genuine  sarcoma  is  remarkable  compared  to  the  statistics  from  other 
places  (in  ( iennany ).  This  is  explained  by  the  fact  that  in  v.  Bergmann's 
clinic  and  the  author's  institute,  even  the  smallest  tumors  in  the  earliest 
stage  of  development  were  subjected  to  microscopical  examination. 

Warts. — It  is  a  fact  of  experience  current  among  the  non-medical 
that  warts  can  be  inoculated  from  one  site  to  another.  The  surgeon 
will  be  surprised  to  find  that  immediate  recurrence  can  take  place 
under  his  own  observation  after  excision.  Jadassohn  and  Lanz  have 
demonstrated  by  experiment  that  it  can  be  transmitted  (to  be  sure,  only 
in  the  same  individual!).  The  existence  of  warts  on  the  unprotected 
parts  of  the  hand  point  to  the  significance  of  external  injuries.  They 
are  more  frequent  in  children,  often  increase  rapidly  from  mechanical 
insults,  suppurate  if  injured,  and  are  very  annoying  especially  if  on  the 
flexor  surface  of  the  hand  and  fingers;  sometimes  they  grow  to  the  size 
of  a  hazelnut,  and  are  then  very  disfiguring.  Occasionally  they  go 
as  they  come,  spontaneously. 

Treatment. — Ligation  is  often  followed  by  recovery,  often  by  in- 
creased recurrence.  They  may  all  disappear  on  the  application  of  nitric- 
acid  or  chromic  acid,  or  they  may  resist  the  acid  entirely.  Radical 
excision  usually  insures  freedom  from  recurrence,  but,  as  mentioned, 
not  always. 

Naevus  pigmentosus  (pigmentary  mole),  without  or  with  hair  (nsevus 
pilostis),  on  the  hand  or  fingers  is  rarely  larger  than  a  pea  or  bean. 
Those  covering  an  entire  finger  or  the  back  of  the  hand  belong  to  the 
greatest  rarities. 

Hemangioma,  Telangiectasis,  Cavernoma. — These  vascular  tumors 
not  infrequently  appear  on  the  hand  and  fingers,  circumscribed  or 
diffuse.  On  superficial  examination  small,  circumscribed  angiomata 
may  be  mistaken  for  warts,  but  the  pure  epidermoid  covering  with  no 
evidence  of  epithelial  growth  and  the  characteristic  color  of  the  vessels 
are  sufficiently  clear  signs.  If  ulcerated,  such  angiomata  may  resemble 
granulomata;  usually,  however,  the  history  gives  sufficient  evidence  of 
the  original  character  of  the  "granuloma." 

Cavernous  tumors  commonly  start  in  the  subcutaneous  veins,  appear 
bluish  through  the  skin,  and  on  palpation  are  felt  as  bulbous  or  berry- 
like  masses  and  are  compressible.     They  are  often  multiple. 

Telangiectases  occur  almost  exclusively  on  the  back  and  sides  of  the 
hand  and  fingers.  The  author  usually  found  them  associated  with 
other  congenital  growths  and  anomalies  of  the  vessels:  lymphangioma, 
circumscribed  or  diffuse  fat-hypertrophy,  and  growths  similar  to  elephan- 
tiasis (once  a  diffuse  cystic  degeneration  of  the  sweat-glands). 

J.  Bell  reports  the  occurrence  on  the  upper  extremity  of  an  "aneurisma 
per  anastomoses" — the  aneurisma  racemosum  of  Virchow,  the  tumeur 
cirsoide  of  Robin,  the  phlebarteriectasia  of  O.  Weber — the  prognosis  of 
which  is  so  unfavorable.  Krause  subjected  a  case  of  Stromeyer  to 
careful  study:  the  disease  was  characterized  by  sacculated  protrusions 
of  the  arteries  and  veins,  involving  chiefly  the  finer  branches;  the  veins 
and  arteries  enter  directly  into  each  other  accompanied  by  many  changes 


3(38  DISEASES  OF  THE  WRIST  AND  HAND. 

in  the  intervening  capillaries.    The  danger  of  rupture  indicates  multiple 
ligation,  or,  still  better,  amputation. 

These  vascular  tumors,  most  of  which  are  supposed  to  be  of  traumatic 
origin  (v.  Bramann),  are  characterized  by  a  rhythmic,  humming  murmur 
transmitted  downward  (v.  Bramann),  which  was  only  absent  in  Wolff's 
case.  In  one  of  Nicoladoni's  cases  there  were  two  small,  discrete, 
pulsating  venous  sacs  on  the  dorsum  of  the  hand,  the  entire  venous 
system  of  the  arm  and  hand  being  markedly  ectatic.  The  venous  pul- 
sation could  be  seen  and  felt  in  the  case  of  cirsoid  aneurism  of  the  hand 
reported  by  Hoffmann,  as  well  as  in  the  case  of  Widenmann  in  v.  Brims' 
clinic,  in  which  there  was  an  accompanying  contracture  of  the  fingers 
and  oedema  of  the  hand  due  to  the  tumor.  In  the  latter  case,  seven 
days  after  ligation  of  the  brachial  amputation  of  the  arm  was  necessary. 
The  specimen  showed  an  abnormal  communication  between  the  inter- 
osseous artery  of  the  forearm  and  a  deep  branch  of  the  cephalic  vein. 

Cirsoid  aneurism  (arterial  cirsoid  aneurism,  arterielles  Rankenan- 
giom,  arterial  cirrous-angioma ),  a  genuine  vascular  tumor  consisting  of 
a  more  or  less  circumscribed  dilatation  of  a  vascular  area  extending  to 
the  capillaries,  is  described  by  Heine.  Wagner  states  that  88  per  cent 
of  all  cirsoid  aneurisms  are  congenital  and  develop  from  telangiectasis, 
as  demonstrated  by  Heine,  Korte,  and  Schtick  with  reasonable  certainty 
in  the  case  of  those  of  the  head,  while  only  12  per  cent,  are  of  traumatic 
origin.  Telangiectasis  develops  chiefly  in  the  capillaries,  whereas 
cirsoid  anetirism  develops  in  the  arterias.  Wagner  found  16  cases  in 
the  literature. 

Treatment. — If  operable,  the  aneurism  should  be  excised.  On 
Thiersch's  recommendation  Schwalbe's  alcohol  injection  has  been  used 
repeatedly  with  success:  rqvj-viij  of  40  to  80  per  cent,  alcohol  every 
two  or  three  days. 

Lipoma. — Lipoma  of  the  hand  or  fingers  is  comparatively  rare.  It 
occurs  either  as  a  diffuse  growth  of  the  cutaneous  adipose  tissue  (see 
section  on  Congenital  Hypertrophy)  or  circumscribed.  It  develops 
from  small  fat-nodules. 

Diagnosis. — The  diagnosis  is  sometimes  difficult.  It  has  often  been 
mistaken  for  hygroma  (Boinet),  ganglion,  and  even  enchondroma.  A 
pseudofluctuation  and  fine  crepitus  occasionally  found  in  lipoma  are  par- 
ticularly liable  to  misinterpretation,  v.  Volkmann  observed  transparency 
in  a  lipoma  of  the  hand.  The  peculiar  direction  of  the  growth  is  of  great 
diagnostic  value;  whereas  the  purse-form  hygroma,  corresponding  to 
the  common  volar  tendon-sheath,  develops  upward  beneath  the  trans- 
verse carpal — annular — ligament,  lipoma  never  oversteps  the  boundary 
set  by  the  dense  ligament,  but  rather  develops  along  the  metacarpals 
toward  the  fingers,  and  may  even  force  the  metacarpals  apart  eases  of 
Perassi,  Bryant,  Hodges,  Wahl)  and  appear  on  the  dorsum.  In  the 
fingers  it  is  almost  always  located  on  the  volar  surface.  Lipoma  on  the 
dorsum  can  be  mistaken  only  by  a  very  cursory  examination. 

Lipoma  arborescens  of  the  tendon-sheaths  was  first  described  by 
Sprengel.     By  reason  of  its  great  rarity  and  the  similarity  of  the  symp- 


TUMORS  OF  THE  HAND  AND  fingers.  369 

toms  it  is  easily  mistaken  for  villifonn  fungus — tuberculous — and  is  lirst 
recognized  upon   incising. 

Treatment. — The  removal  of  large  palmar  lipomata  is  usually  simple. 
In  a  boy  four  years  old  Ktister  excised  a  lipoma  which  extended  from 
the  ulnar  border  of  the  little  finger  to  the  elbow. 

Fibroma. — Genuine  fibroma  of  the  skin  of  the  hand  and  fingers 
belongs  to  the  rarities.  Its  site  of  origin  is  more  frequently  the  palmar 
fascia,  its  radiations  extending  to  the  fingers,  the  tendon-sheaths  and 
tendons,  and  occasionally  the  joints  and  periosteum.  Callus  of  the  ten- 
doncaused  byinjuries,  overstretching,  and  laceration  is  to  be  classified  with 
fibroma;  if  the  ensuing  proliferation  of  the  interfibrillar  tissue  of  the  ten- 
dons exceeds  the  physiological  amount  of  cicatrization  and  involves  the 
tendon-cells,  the  callous  masses  appear  as  firm  spindle-shaped  tumors 
along  the  tendon.  (See  also  Snapping  Finger.)  The  first  symptom 
of  Dupuytren's  contraction  of  the  palmar  aponeurosis  may  he  single 
or  multiple  small  fibromata  in  the  palm.  Certainly  not  a  few  of  the 
fibromata  of  the  hand  and  fingers  are  due  to  trauma.  Their  greater 
frequency  on  the  flexor  surface  of  the  finger  than  on  the  extensor  surface 
speaks  for  this.  Heller  reports  the  ratio  of  volar  to  dorsal  fibromata  in 
the  patients  at  the  author's  polyclinic  as  13  is  to  3. 

Diagnosis. — Fibromata  of  the  skin  are  firmly  attached  to  the  latter, 
easily  movable  on  the  underlying  parts,  those  of  the  tendon-sheaths 
being  movable  chiefly  in  the  transverse  direction,  while  those  of  the 
tendons  follow  the  movements  of  the  latter.  Even  the  larger  fibromata 
of  the  tendon-sheaths  do  not  usually  become  adherent  to  the  underlying 
bone. 

Treatment. — Fibromata  should  be  removed  as  soon  as  they  cause 
functional  disturbance,  which  happens  early-  if  the  tendon-sheaths  or 
tendons  are  the  seat  of  the  growth. 

Sebaceous  Cysts. — Atheroma  occurs  on  the  dorsum,  but  never  in  the 
palm.  The  epidermal  cysts  observed  in  the  palm  (cyst  epidermique, 
tumeur  perle,  dermoide,  cyste  sebacee)  are  to  be  regarded  for  the  greater 
part  as  of  traumatic  origin.  (Reverdin,  Le  Fort,  Garre,  and  others.) 
Their  interpretation  is  still  within  the  bounds  of  discussion.  Franke, 
who  thinks  they  should  be  termed  epidermoids,  admits  the  traumatic 
origin  only  in  a  slight  percentage.  Based  upon  his  own  experience 
and  observation  as  carefully  verified  by  the  history  and  microscope, 
and  upon  the  view  of  Reverdin  and  Garre,  the  author  would  like  to 
indicate  the  etiological  significance  of  trauma. 

Clinically  the  epithelial  cysts  in  question  are  very  similar  to  sebaceous 
cysts,  vary  in  size  from  that  of  a  millet-seed  to  that  of  a  hazelnut,  have 
a  smooth,  rounded  surface,  feel  of  cartilaginous  hardness,  and  are 
tensely  elastic  or  distinctly  fluctuating.  The  skin  is  movable  over  the 
tumor;  or  if  the  tumor  is  large,  is  tense,  fissured,  callous,  and  scaly, 
and  sometimes  shows  macroscopical  cicatricial  changes.  Their  develop- 
ment not  infrequently  extends  over  months  and  years.  They  occur 
almost  without  exception  in  men,  have  never  been  seen  in  children, 
rarely  in  women.  The  index  finger  is  most  often  affected,  sometimes 
Vol.  Ill— 24 


370 


DISEASES  OF  THE  WRIST  AND  HAND. 


the  volar  surface  of  the  other  fingers,  rarely  the  palm.  All  of  the  author's 
3  cases  were  of  the  right  hand,  2  in  the  palm.  The  growth  is  preceded 
by  incised  or  puncture-wounds,  bites,  or  tears.  Kummer  found  such 
an  epithelial  cyst  formed  about  a  foreign  body  (needle-point).  Its 
occurrence  presupposes  a  traumatic  involution  of  a  portion  of  vascular 
epidermis,  capable  of  regeneration.  Thorough  excision  is  the  only 
reliable  means  of  preventing  recurrence. 


Epithelial  cyst  of  the  palm. 

The  fibrous  capsule  of  the  epithelial  cyst  is  not  dense  like  that  of 
the  sebaceous  cyst,  but  usually  delicate  with  few  nuclei.  It  is  covered 
with  several  layers  of  more  or  less  cuboid  cells  with  distinct  large  nuclei, 
analogous  to  the  outer  layers  of  the  epithelium.  The  central  masses 
of  epithelium  are  transformed  into  a  sebaceous  paste  containing  choles- 
terin,  but  never  contain  hair  or  other  forms  of  epithelial  proliferation. 

Neuroma;  Paraneurotic  Fibroma. — Genuine  neuroma  and  "para- 
neurotic  fibroma,"  classified  as  neuroma,  occurring  on  the  hand  and 
fingers  are  almost  always  due  to  trauma.  Foreign  bodies  (especially 
pieces  of  glass)  are  not  infrequently  found  in  them  as  the  immediate 
cause  of  the  new  formation. 

Multiple  Enchondroma. — The  metacarpals  and  phalanges  are  appar- 
ently the  favorite  spots  for  the  development  of  multiple  enchondromata. 
(Figs.  229  and  230.)  Occasionally  they  grow  to  an  enormous  size,  to 
that  of  a  child's  head.  As  long  as  they  consist  purely  of  cartilage  they 
belong  to  the  benign  tumors.  Their  removal  is  not  difficult,  but  the  base 
of  the  tumor  should  be  excised  carefully,  otherwise  local  recurrence  is 


TUMORS  OF  THE  UASD  AND  FINGERS. 
Fig.  229. 


371 


Multiple  enchondromata  of  the  left  hand.    (v.  Bruus.) 
Fig.  230. 


X-ray  picture  of  Fig.  229. 


372  DISEASES  OF  THE  WRIST  AND  HAND. 

possible.  Foci  of  enchondroma  embedded  in  the  adjacent  medulla  may 
escape  detection  during  the  operation,  remain  latent,  and  develop 
secondarily  and  simulate  a  recurrence.  The  growth  of  an  enchondroma 
usually  does  not  stop  with  the  completion  of  the  general  growth.  If 
it  undergoes  regressive  metamorphosis,  myxomatous  degeneration,  or 
sarcomatous  transformation  of  the  interstitial  tissue,  its  very  malignant 
character  is  soon  shown  by  metastases. 

Periosteal  Osteoma. — Circumscribed  periosteal  osteoma  in  the 
fingers  is  not  a  frequent  observation  in  spite  of  the  manifold  oppor- 
tunities for  traumatic  insults.  On  account  of  the  hardness  of  the  tumors 
their  proper  interpretation  is  usually  easy.  The  base  is  broad.  They 
often  cause  such  slight  disturbance  that  their  removal  will  be  purely 
on  aesthetic  grounds. 

Chondral  osteoma  with  multiple  cartilaginous  exostoses  is  also  rare 
in  the  fingers;  only  small  osteomata  are  occasionally  found  on  the 
carpal  bones.  The  defects  accompanying  the  formation  of  the  exostoses 
are  much  more  significant  for  the  hand.  Exostoses  and  the  production 
of  defects  are  especially  frequent  on  the  ulna  and  cause  a  pathological 
position  of  abduction  of  the  hand  with  simultaneous  subluxation  of 
the  proximal  end  of  the  radius.  In  such  cases  Bessel-Hagen  attempted 
to  correct  the  position  by  resecting  the  lower  end  of  the  radius. 

Sarcoma. — Sarcoma  of  the  skin  [sarcoma  molluscum],  so-called,  has 
no  characteristics  peculiar  to  the  hand.  Important,  however,  is  the  often 
extremely  slow  growth  at  the  onset  and  the  later  rapid  development  after 
incomplete  operation.  Melanotic  sarcoma,  starting  in  a  nsevus  and  not 
infrequently  situated  by  choice  in  the  region  of  the  nail,  gives  evidence 
of  very  pronounced  malignancy  like  all  melanotic  tumors.  Sarcoma 
originating  in  the  bone  is  seen  on  the  lower  end  of  the  radius  or  ulna,  on 
the  small  carpal  bones,  on  the  metacarpals  or  phalanges.  It  develops  pre- 
ferably from  the  spongiosa,  more  rarely  from  the  periosteum,  and  is  more 
often  a  soft  spindle-cell  than  round-cell  sarcoma.  It  is  almost  always  soli- 
tary, attains  considerable  size,  and  gradually  absorbs  the  structure  of  the 
involved  bone  so  completely  that  the  anatomy  of  the  latter  is  entirely 
obliterated.  The  cartilage  usually  resists  the  tumor  for  a  long  time, 
and  is  sometimes  the  only  evidence  of  the  topography  present  in  the 
tumor  masses.  On  account  of  the  rich  vascularity  by  which  these  tumors 
are  distinguished  and  their  great  tendency  to  metastasis  they  belong 
among  the  most  malignant  tumors  known.  They  occur  almost  entirely 
in  youth  and  middle  life. 

Giant-cell  sarcoma,  in  contrast,  almost  always  starts  in  the  periosteum 
or  tendon-sheath.  It  is  more  frequent  in  the  long  bones.  The  author 
has  extirpated  such  in  a  ten-year-old  boy,  and  repeatedly  in  middle-aged 
men  from  the  phalanges,  and  has  demonstrated  the  anatomical  basis 
and  microscopical  structure.  The  prognosis  is  the  same  as  that  of 
giant-cell  sarcoma  in  general,  and  is  therefore  comparatively  favorable. 

Fibrosarcoma  may  arise  in  the  nerves  or  tendon-sheaths.  The  latter 
origin  is  more  frequent  according  to  the  author's  microscopical  studies 
than  is  apparent  from  the  literature.     The  micro-anatomical  details 


TUMORS  OF  THE  HAM)  AM)  FINGERS.  373 

have  been  published  by  Heller.  In  like  manner  in  a  twelve-year-old 
boy,  a  man  of  forty-five,  and  in  a  large  series  of  patients  ranging  in 
years  between  these  two,  the  author  has  been  able  to  obtain  unquestion- 
able microscopical  evidence  of  the  genesis  in  the  tendon-sheath.    The 

tendon-sheaths  of  the  ringers  are  much  more  frequently  affected  than 
those  above  the  wrist,  a  circumstance  which  speaks  for  the  influence 
of  trauma.     The  treatment  consists  in  radical  removal. 

A  benign  subungual  angiosarcoma  has  been  described  by  Kraske, 
a  small  tumor  glowing  slowly  for  years  in  the  middle  of  the  nail  bed  in 
the  form  of  a  bluish  spot,  producing  excruciating  pain  on  pressure;  on 
removing  the  nail  it  shows  a  distinct  fibrous  capsule  and  may  have 
produced  a  shallow  depression  in  the  bone. 

Epithelial  Carcinoma. — Epithelial  carcinoma  occurs  almost  exclu- 
sively on  the  dorsum,  and  sometimes  develops,  often  under  observation 
of  the  surgeon,  from  a  formerly  benign  ulcerating  process,  a  cicatrix, 
or  a  wart.  Rudolf  Volkmann  emphasized  the  malignancy  of  carcinoma 
developing  from  congenital  warts  in  contrast  to  the  benignancy  of 
carcinoma  arising  from  acquired  warts.  The  malignant  transformation 
is  shown  usually  by  sudden  increase  in  size,  induration  of  the  edges  and 
base  of  the  ulcers,  and  in  warts  by  beginning  spontaneous  ulceration, 
a  tendency  to  bleeding,  and  often  by  annoying  pruritus.  The  author 
has  repeatedly  been  able  to  follow  the  process  of  development  in  patients 
who,  on  account  of  the  distance  of  their  home,  consulted  him  only  at 
rare  intervals  or  through  fear  of  operation  kept  postponing  the  proposed 
operative  measures  only  to  have  recourse  later  to  the  knife.  In  regard 
to  the  frequency  of  carcinoma  in  the  extremities,  according  to  Rudolf 
Volkmann  and  W.  Michael,  in  105  genuine  epithelial  carcinomata  of 
the  upper  extremity,  1)4  were  on  the  back  of  the  hand,  3  in  the  palm. 


CHAPTER   XXI. 

OPERATIONS  ON  THE  WRIST  AND  HAND. 

GENERAL  RULES,  LIGATION,  PLASTIC  OPERATIONS  ON  THE 

TENDONS. 

In  the  following  only  the  operations  will  be  mentioned  which  are 
worthy  of  consideration  on  grounds  of  practical  experience. 

In  the  last  four  years  the  author  has  had  an  opportunity  to  see,  treat, 
and  finally  to  pass  judgment  on  not  less  than  6000  surgical  affections 
of  the  hand  and  wrist.  Of  these,  about  2000  were  very  complicated 
injuries,  400  were  fractures,  1300  panaritia,  600  severe  phlegmon  of 
the  hand,  200  frost-bites  and  burns,  160  tuberculosis,  and  200  were 
tumors.  Disregarding  the  compilation  formerly  made  by  Thiersch 
and  Trendelenburg,  these  figures  furnish  the  basis  for  the  preceding 
and  following  observations  in  regard  to  the  indications  and  technic  of 
operation. 

In  all  operations  on  the  wrist  and  hand  the  incision  should  avoid  as 
much  as  possible  the  flexor,  namely,  the  prehensile  surface  of  the  hand 
and  fingers;  all  flaps  made  to  cover  in  stumps  should  be  taken  largely 
from  the  flexor  surface,  and  so  applied  on  the  dorsum  that  the  line  of 
suture  avoids  the  volar  surface.  Incisions  and  sutures  should  also  avoid 
the  end-cushions  of  the  fingers,  the  incision  being  made  without  exception 
on  the  side. 

Strict  asepsis  is  imperative  in  all  procedures  on  non-infected  tissues, 
as  inflammation  can  leave  behind  for  a  long  time  a  sensitiveness  during 
use  which  is  not  infrequently  taken  advantage  of  by  patients  who  are 
unwilling  or  afraid  to  work. 

It  is  advisable  to  use  local  anaesthesia  as  much  as  possible;  for  the 
fingers  the  Curling-Oberst-Reclus  method;  about  the  hand  (metacarpus) 
Schleich's  method;  about  the  wrist  Oberst's  method  as  improved  by 
Manz,  Holscher,  and  Berndt.  The  author  has  already  disctissed  the 
limitations  of  conservative  surgery  in  the  treatment  of  wounds  of  the 
fingers  and  hand;  still  it  should  be  repeated  that  although  it  is  an  im- 
portant rule  to  save  as  much  as  possible,  it  should  not  be  carried  to  an 
extreme  A  faultless  covering  over  the  amputated  stump  is  of  greatest 
importance  for  the  future  function.  Insufficient  covering  over  the 
stump  and  thin,  sensitive  cicatrices  adherent  to  the  bone  are  easily 
injured  and  compromise  the  usefulness  and  earning-efficiency  more 
than  a  shorter  stump.     (See  also  page  317.) 

Accordingly  in  mutilating  wounds  it  is  always  best  to  remove  sufficient 
bone  to  prevent  any  tension  in  the  sound  skin  sutured  over  it.  This 
(374) 


PLASTIC  OPERATIONS  ON  THE  TENDONS.  375 

applies  also  to  all  wounds  of  the  finger-tips  in  which  the  bone  is  exposed 

by  transverse  amputation  of  the  end-portion.  It'  this  end-piece  can  still 
be  used,  one  may  try  to  reunite  it;  if  not,  the  surface  of  the  wound 
should  not  be  skin-grafted,  but  rather  sufficient  hone  removed  by 
exarticulation  or  amputation  to  obtain  a  good  covering  of  the  soft  parts. 

In  order  to  do  justice  to  the  demands  of  conservative  treatment,  the 
author  advises  the  inexperienced  to  defer  the  decision  as  to  the  removal 
«>f  the  finger  till  the  extent  of  its  usefulness  is  more  clearly  established. 
The  experienced  will  usually  decide  quickly  in  regard  to  preserving  or 
amputating.  It  is  impossible  to  give  any  generally  applicable  rule. 
Every  surgeon  should  always  be  as  conservative  as  possible  in  dealing 
with  mutilation  of  the  entire  hand,  such  as  is  caused  by  machinery, 
shot-wounds,  etc.  "If  in  this  case  one  should  desire  to  hasten  the 
recovery  by  removing  portions  of  bone  or  entire  fingers  sufficiently  to 
fully  cover  in  the  defects  and  the  wounds,  an  unjustifiable  sacrifice 
would  always  be  made."  (Ledderhose.)  In  describing  complicated 
wounds  and  their  treatment  the  author  has  already  given  space  to  con- 
siderations bearing  on  this  subject. 

Ligation  of  the  Radial  Artery. — To  ligate  the  radial  artery  above 
the  wrist,  an  incision  f  to  1{  inches  long  is  sufficient,  if  made  midway 
between  the  flexor  carpi  radialis  and  the  attachment  of  the  supinator 
longus  on  the  styloid  process  of  the  radius;  the  artery  lies  beneath  the 
skin  and  fascia. 

Ligation  of  the  Ulnar  Artery. — This  is  done  with  comparative  ease 
to  the  inner  side  (ulnar)  of  the  flexor  carpi  ulnaris,  the  point  of  insertion 
of  which  (the  pisiform  bone)  is  always  easily  felt;  the  artery  at  this 
point  is  accompanied  by  the  ulnar  nerve  and  runs  over  the  annular 
ligament  to  the  palm  to  form  the  superficial  palmar  arch.  The  vessel 
is  usually  accompanied  by  two  veins.  Variations  in  its  course  are  not 
rare,  but  cannot  be  discussed  here.  In  regard  to  ligation  for  injuries 
of  the  palmar  arch,  see  page  315. 

For  wounds  of  the  nerves  the  author  recommends  preferably  the 
"  paraneurotic  "  suture.  The  indications  for  operation  and  the  technic 
of  suture  of  the  tendons  have  already  been  discussed. 

Plastic  Operations  on  the  Tendons. — The  surgeon  has  to  distinguish 
between  division  of  the  tendons  and  defects  of  the  tendons,  and  between 
recent  injury  and  old  cases  with  cicatrization.  Recent  cases  of  traumatic 
division  by  incised  wounds  are  to  be  sutured  immediately.  Recent 
wounds  accompanied  by  loss  of  substance  will  require  immediate  plastic 
operation  only  exceptionally,  as  in  this  case  the  surgeon  is  usually 
dealing  with  extensive  injuries  the  aseptic  nature  of  which  must  be 
verified  before  sacrificing  any  tendon  material  for  plastic  operation,  as 
in  the  event  of  infection  or  necrosis  the  latter  is  also  sacrificed.  There- 
fore primarily  only  suture  of  the  tendon  or  operative  abstinence! 

In  old  cases  with  functional  loss  of  the  tendon  the  question  is  whether 
there  is  merely  division  or  defect  caused  by  the  injury,  or  defect  follow- 
ing inflammatory  destruction.  Cases  of  the  latter  kind  are  almost 
always  hopeless.     The  usually  deep  cicatrization  with  changes  in  the 


376 


OPERATIONS  ON  THE  WRIST  AND  HAND. 


Fig.  231. 


adjacent  tissues  almost  exclude  any  beneficial  operation.  It  will  gener- 
ally depend  upon  the  vocation  and  desire  of  the  patient  as  to  whether 
it  will  not  give  the  best  functional  result  in  such  cases  to  remove  a  part 
of  or  the  entire  finger.  In  the  case  of  traumatic  defect  (loss  of  substance), 
the  extent  of  the  defect  and  the  circumstance  as  to  whether  one  or  more 
tendons  are  injured  are  decisive.  Defects  up  to  4  inches  can  be  over- 
come by  plastic  operation.  If  there  are  large  defects  of  several  tendons, 
the  operative  result  will  leave  much  to  be  desired.  The  most  grateful 
contingent  for  plastic  operations  on  the  tendons  of  the  hand  is  formed 
by  the  cases  of  diastasis  of  incised  tendons  and  of  paralysis  of  certain 

groups  of  muscles  with  the  func- 
tion retained  in  others,  such  as  re- 
sult from  cerebral  or  spinal  infantile 
paralysis  or  otherwise  uncurable 
paralysis  of  the  radial,  median,  or 
ulnar  nerve. 

For  the  diastasis  following  incised 
wounds  there  are  three  possibilities: 
1.  Plastic  flaps.  2.  Incomplete  su- 
ture. 3.  Tendon-transplantation: 
(a)  by  splitting  an  adjacent  tendon 
and  suturing  one-half  to  the  distal 
stump  of  the  divided  tendon  (in- 
traparalytic  transplantation  of  iso- 
functionating  tendons)  ;  (b)  by  im- 
planting the  distal  stump  of  the 
severed  tendon  into  an  active,  ad- 
jacent tendon  (intrafunctional  trans- 
plantation of  the  paralyzed  stump). 
The  methods  given  under  3  are  also 
suitable  for  plastic  transplantation 
in  paralysis. 

1.  Plastic  Flaps. — The  three  dia- 
grams (Fig.  231)  explain  themselves 
and  do  not  require  further  descrip- 
tion. The  author  has  always  been 
satisfied  with  the  results  of  method  a. 
author  applies  the  term  "incomplete 
h  artificial  material  is  laid  between  the 


III 


Plastic  methods  of  tendon-suture. 


2.  Incomplete    Suture. — The 
suture  "  to  all  methods  in  whi( 


Fig.  232. 


Partial  approximation  with  silk. 


stumps  to  produce  cicatrization  in  the  defective  gap  and  so  restore  the 
function  of  the  tendon  (case  of  Gluck).  The  simplest  method  is  to 
connect  the  stumps  with  fine  silk  sutures  drawn  lightly,  not  too  firmly, 


AMPUTATION  AND  EXABTICULATION.  ;;77 

together.    (Fig.  I':!-'.      In  the  figure  only  two  sutures  arc  shown,  although 
it  is  advisable  to  use  more.    This  method  presupposes  thai  the  cicatrized 
and  adherent  stumps  are  first  loosened.     The  result  of  the  method  is 
uncertain. 
;!.   Tendon-transplantation.     (Fig.  i'-'!.').) 

I  to.  233. 


Tendon-transplantation:  a,  intfaparalytic  transplantation  of  a  split  portion  of  an  isofunctionating 
tendon;  b,  intrafunctional  implantation  of  the  paralytic  stump. 


AMPUTATION  AND  EXARTICULATION. 

Ever  since  anaesthesia,  artificial  anaemia,  and  asepsis  have  been  added 
to  surgical  technics  amputation  and  exarticulation  have  become  such 
simple  surgical  measures  that  each  problem  is  easily  accessible  to  the 
knife  if  the  anatomy  is  considered.  The  author  therefore  omits  many 
details  which  form  a  part  of  the  operative  course  on  the  cadaver  and 
confines  himself  to  describing  the  principle  methods  of  incision. 

Exarticulation  of  the  Hand. — Amputation  of  the  hand  at  the  wrist- 
joint  is  only  admissible  when  no  portion  of  the  hand  can  be  saved  for 
a  stump.  The  formation  of  the  flap  is  important;  the  covering  is  best 
taken  from  the  volar  or  radial  side  (thenar  flap  of  Dubreuil).  Steps 
in  the  operation:  forcible  flexion  of  the  hand;  curved  dorsal  skin-flap 
convex  downward,  beginning  \  inch  below  the  styloid  process  of  the 
ulna  and  ending  %  inch  below  the  styloid  process  of  the  radius;  division 
of  the  extensors  and  the  lateral  and  dorsal  ligaments;  disarticulation  of 
the  carpus;  transverse  division  of  the  flexor  tendons;  formation  of  a  full 
volar  flap  to  be  sutured  on  the  dorsum ;  ligation  of  the  ulnar  and  radial 
artery  and  occasionally  of  a  terminal  branch  of  the  interosseus;  high 
division  of  the  median,  ulnar,  and  radial  nerves.  The  flap  may  be 
taken  from  the  radial  side,  including  the  muscles  of  the  thumb  with 
advantage,  because  by  this  means  any  cicatrization  over  the  most  prom- 
inent part  of  the  stump,  namely,  the  styloid  process  of  the  radius,  is 
avoided;  or  a  circular  incision  may  be  made  beginning  1  to  1  \  inches 
below  the  styloid  process. 

Amputation  of  the  Metacarpus  Excluding  the  Thumb. — This  ampu- 
tation is  required  especially  for  extensive  mutilation,  gunshot-wounds, 
etc.     One  should  consider  well  beforehand  how  much  can  be  saved  of 


378  OPERATIONS  ON  THE  WRIST  AND  HAND. 

the  metacarpals  in  order  to  preserve  the  prehensile  power  as  much  as 
possible.  The  aim  is:  the  greatest  possible  preservation  of  the  meta- 
carpals, formation  of  a  good  flap  from  the  palm;  if  this  is  not  possible, 
from  the  dorsum  or  adjacent  remnants  of  skin.  Steps  in  the  operation: 
dissection  upward  of  a  semicircular  volar  flap  close  to  the  metacarpals 
to  the  point  of  amputation  of  the  bones;  transverse  incision  of  the 
skin  on  the  dorsum  \  inch  below  the  level  of  the  stumps,  removal  of 
the  bones  with  a  tendon  saw  after  dividing  the  interossei;  ligation  of 
the  five  digital  arteries;  high  division  of  the  nerves;  suture. 

Amputation  of  a  Single  Metacarpal. — Amputation  of  the  thumb 
is  best  performed  (Walther,  French  method)  by  forcibly  abducting  the 
thumb  and  earning  the  knife  through  the  middle  of  the  interdigital  fold 
close  to  the  first  metacarpal  and  then  upward,  the  joint  between  the 
first  metacarpal  and  trapezius  being  opened  correspondingly  from  the 
ulnar  side;  the  ligaments  are  divided  about  the  base  of  the  metacarpal, 
the  knife  carried  to  the  radial  side,  and  the  division  continued  downward 
with  the  formation  of  a  large  flap. 

The  metacarpal  is  also  easily  disarticulated  through  an  oval  (racket) 
incision,  the  point  being  proximal,  the  base  distal.  Kocher  recommends 
that  all  the  muscles  of  the  thumb  should  be  preserved  intact  and  the 
metacarpus  disarticulated  through  a  dorsal  incision  running  along  the 
ulnar  side  of  the  first  metacarpal  and  ending  as  an  oval  incision  at 
the  level  of  the  first  phalanx. 

For  exarticulation  or  amputation  of  the  third  or  fourth  metacarpal 
one  uses  a  volar  and  dorsal  longitudinal  incision  continued  laterally 
below  to  meet  at  the  sides  at  the  level  of  the  interdigital  folds.  The  latter 
are  then  incised  and  the  parts  dissected  close  to  the  bone  to  the  point 
of  amputation  or  to  the  joint;  the  adjacent  metacarpals  are  retracted 
laterallv,  the  bone  divided  with  a  pointed  saw  or  disarticulated  at  the 
joint;  ligation;  careful  suture,  especially  in  the  palm. 

To  avoid  cicatrices  in  the  palm,  the  metacarpal  may  be  removed 
through  a  dorsal  longitudinal  incision  ending  as  an  oval  incision  at  the 
level  of  the  first  phalanx  (racket  incision). 

Amputation  of  the  Fingers  at  the  Metacarpophalangeal  Joint. — 
For  the  thumb  and  index  finger  this  is  best  performed  by  making  an 
external  lateral  flap;  for  the  fifth  finger  by  an  internal  lateral  flap;  the 
third  and  fourth  by  an  oval  incision  with  the  point  on  the  dorsum. 

The  line  of  the  joint  is  easily  felt  on  the  dorsum  by  moderately  flexing 
the  finger,  and  can  be  seen  by  pulling  on  the  finger.  In  making  the  oval 
incision  the  finger  is  hyperextended.  In  suturing,  in  order  to  obtain 
a  movable  covering  over  the  head  of  the  metacarpals,  the  lateral  and 
volar  incisions  should  not  be  made  too  high.  Slight  excess  of  skin  does 
not  impair  the  later  usefulness  of  the  hand.  In  disarticulating  the 
finger  the  two  digital  arteries  are  to  be  ligated,  and  the  adjacent 
nerves  freed  and  cut  off  at  a  higher  level.  In  amputating  the  middle 
and  ring  fingers,  if  it  is  possible,  particularly  if  the  wound  is  aseptic, 
the  author  always  removes  the  head  of  the  metacarpal  so  as  to 
be  able  to  approximate   the   heads  of   the   adjacent   metacarpals   and 


RESECTION  OF  THE  WRIST-JOINT.  379 

insure  the  best  possible  closure  of  the  hand.  For  this  purpose  the 
incision  is  made  a  little  higher  on  the  dorsum,  ,  to  1  inch  above  the 
joint.  The  finger  is  disarticulated,  the  head  of  the  metacarpal  freed 
to  above  its  neck,  and  sawed  off  with  a  pointed  saw  or  removed  with 
the  sharp  Liston  bone-shears. 

Exarticulation  of  the  Middle  and  End- phalanges.- -The  continua- 
tion of  the  interphalangeal  fold  between  the  first  and  middle  phalanges 
marks  the  point  on  the  dorsum  for  the  incision  to  open  the  joint.  The 
fold  between  the  second  and  third  phalanges  is  not  an  accurate  guide, 
so  that  it  is  better  to  make  the  incision  according  to  the  old  rule  \  inch 
below  the  most  prominent  point  of  the  joint,  the  latter  being  flexed 
forcibly.  This  opens  the  joint  and  gives  sufficient  material  for  the 
flap.  The  lateral  ligaments  are  then  divided;  a  full  volar  flap  is  then 
made  which  should  include  the  insertion  of  the  tendon  of  the  flexor 
profundus  and  all  the  soft  parts. 

Amputation  of  the  Phalanges. — Large  dorsal  and  volar  flaps  are 
formed  by  a  circular  incision  from  which  two  lateral  incisions  run  upward; 
the  ends  of  the  tendons  should  be  sutured  together  over  the  stump,  in 
deciding  between  amputation  and  exarticulation  it  should  be  remem- 
bered that  even  small  stumps  of  the  middle  or  end-phalanges  are  useful, 
whereas  short  stumps  of  the  first  phalanx  are  in  the  way,  so  that  in 
the  latter  case  Adelmann's  operation  as  described  is  preferable.  In 
septic  affections  exarticulation  is  always  preferable  to  amputation. 


RESECTION  OF  THE  WRIST-JOINT. 

Resection  at  the  wrist-joint  or  of  the  entire  wrist-joint  is  indicated 
for  wounds,  especially  gunshot-wounds,  septic  infection,  and  tuber- 
culosis. The  available  statistics  of  gunshot-wounds  are  chiefly  from 
the  preantiseptic  period.  Present  knowledge  of  the  action  of  modern 
firearms  would  seem  to  indicate  that  the  treatment  of  the  greater  number 
of  gunshot-wounds  should  be  conservative.  In  wounds  from  heavy 
ordnance,  as  in  the  case  of  numerous  machinery  injuries,  the  damage 
to  the  wrist  constitutes  only  a  part  of  the  mutilations  involving  the  hand 
or  forearm,  but  in  this  case  typical  primary  resection  does  not  come 
in  question.  In  regard  to  the  indication  for  surgical  interference  in  septic 
processes  the  author  has  already  spoken  in  describing  the  latter.  The 
mode,  of  procedure  will  depend  upon  the  site  of  the  infection  or  lie 
determined  by  the  same  general  technical  considerations  applying  to 
tuberculosis  of  the  wrist.  For  this  reason  the  author  desires  to  discuss 
the  latter  more  in  detail. 

The  prognosis  in  general  of  resection  of  the  wrist  should  be  mentioned 
briefly.  Its  relatively  unfavorable  functional  results  have  been  reported 
from  all  sides,  and  have  caused  many  surgeons  to  hesitate  to  perform 
resection.  In  all  cases  in  which  the  author  was  compelled  to  do  primary 
partial  resection  for  complicated  injuries,  partial  mangling  of  the  carpal 
bones,   or  compound   dislocations,   he  has  obtained   either   partial   or 


380  OPERATIONS  ON  THE  WRIST  AND  HAND. 

complete  ankylosis  at  the  wrist.  The  result  is  usually  due  to  the 
severity  of  the  injury.  On  the  other  hand,  in  almost  all  these  cases 
in  which  all  useless  portions  of  bone  were  removed  recovery  was  rapid 
and  uninterrupted.  The  results  of  resection  for  sepsis  were  about  the 
same.  The  author  has  never  had  to  amputate  secondarily,  but  never- 
theless almost  always  obtained  ankylosed  joints.  The  treatment  here 
is  concerned  chiefly  in  checking  the  infection  with  all  the  means  of 
drainage  and  packing. 

The  functional  results  in  tuberculosis  are  somewhat  different,  espe- 
cially if  the  end  of  the  radius  and  ulna,  and  if  possible  also  part  of  the 
distal  carpal  bones,  can  be  preserved,  in  which  case  the  subsequent 
usefulness  of  the  hand  may  be  very  satisfactory.  In  most  of  the  cases 
the  author  begins  the  treatment  by  injecting  iodoform.  The  action  of 
the  latter  in  patients  up  to  the  fortieth  year  is  often  surprisingly  beneficial. 
Even  in  the  cases  in  which  the  tuberculous  process  appears  to  be  worse 
after  the  first  injection  persistence  in  its  use  is  often  rewarded  by 
excellent  results.  If  the  examination,  however,  especially  with  the  .r-ray, 
leaves  no  doubt  as  to  the  involvement  of  the  larger  part  of  the  carpal 
bones,  and  if  the  age  and  general  condition  of  the  patient  do  not  demand 
amputation,  careful  total  resection  of  the  wrist  may  be  well  fitted  to 
restore  fairly  good  use  of  the  hand.  The  creation  of  useful  methods 
of  operation  is  closely  connected  with  the  names  Lister,  v.  Langenbeck, 
Oilier,  Konig,  and  Kocher. 

Resection  of  the  wrist  is  not  a  simple  operation  under  any  conditions' 
all  arteries,  nerves,  tendons,  and,  if  possible,  tendon-sheaths  should  be 
avoided,  and  as  much  of  the  periosteum  preserved  as  possible.  The 
ligaments  are  in  part  very  firm;  the  anatomy  is  obliterated  by  the 
inflammatory  processes.  On  the  other  hand,  softening  or  partial 
destruction  of  the  bones  often  make  the  operation  easier  than  expected. 
All  resections  should  be  done  under  application  of  the  Esmarch. 

Total  Resection  of  the  Carpus  with  Lister's  Bilateral  Longitudinal 
Incision. — Based  upon  the  experience  that  the  infectious  process  often 
advances  along  the  complicated  communications  of  the  joints,  Lister 
advocated  total  resection.  His  method  is  as  follows:  A  longitudinal 
incision  1  inch  long  is  made  upward  from  the  styloid  process  of  the 
radius  and  down  to  the  bone;  from  the  same  point  on  the  process  a 
skin-incision  is  carried  1  inch  downward  to  the  inner  side  of  the  first 
metacarpophalangeal  joint,  to  avoid  the  tendons  of  the  abductor  pollicis 
longus,  extensor  pollicis  longus  and  brevis;  from  this  point  it  is  con- 
tinued on  the  dorsum  to  the  middle  of  the  radial  border  of  the  second 
metacarpal.  The  insertions  of  the  extensor  carpi  radialis  longus  and 
brevis  are  then  freed  and  the  periosteum  lifted  off  in  both  these  incisions. 
A  second  incision  1  inch  long  is  then  made  from  the  styloid  process 
of  the  ulna  upward  down  to  the  bone  and  1  inch  downward  to  the  base 
of  the  fifth  metacarpal.  The  insertion  of  the  extensor  carpi  ulnaris 
is  divided,  the  tendon  being  lifted  off  with  the  skin.  The  extensor 
tendons  lying  between  the  two  incisions,  radial  and  ulnar,  are  then 
lifted  off  carefully  and  the  dorsal  and  inner  lateral  ligament  divided. 


RESECTION  OF  THE  WRIST- JOINT.  33  \ 

The  flexor  tendons  are  lifted  oil'  in  the  same  way;  the  unciform  process 
of  the  unciform  is  cut  with  bone-shears,  the  carpal  hones  extracted 
through  the  ulnar  incision  with  bullet-forceps,  the  hones  of  the  forearm 
protruded  through  the  ulnar  incision  and  sawed  off,  leaving  the  styloid 
process  of  the  ulna.  Lister  finally  added  resection  of  the  base  of  the 
metacarpals  and  the  trapezium.  The  pisiform  and  unciform  are  left, 
the  radial  incision  closed,  the  ulnar  incision  left  open  in  the  middle. 
The  radial  artery  should  he  avoided  in  removing  the  trapezium.  The 
latter  can  often  be  preserved  because  it  is  rarely  diseased.  Huter  saves 
the  articular  ends  of  the  radius  and  ulna  if  possible  (on  account  of  pro- 
nation and  supination);  also  the  base  of  the  metacarpals.  The  objection 
made  to  Lister's  method,  that  the  ulnar  artery  is  injured  by  the  ulnar 
incision,  is  overcome  if  the  proximal  incision  is  shortened. 

v.  Langenbeck's  Dorsoradial  Incision.— This  incision  is  much  sim- 
pler, and  is  in  general  use  at  the  present  time.  Beginning  at  the  middle 
of  the  second  metacarpal  close  to  its  ulnar  border,  an  incision  is  made 
about  3-V  inches  upward  over  the  epiphysis  of  the  radius.  The  common 
tendon-sheath  of  the  extensors,  including  that  of  the  index  ringer,  is 
to  be  avoided  and  retracted  toward  the  ulna.  Between  it  and  the 
sheath  of  the  extensor  pollicis  longus  the  annular  ligament  is  incised 
down  to  the  radius.  The  edges  of  the  wound  are  retracted,  the  capsule 
of  the  radiocarpal  joint  divided  longitudinally  and  peeled  off  with  the 
ligaments  and  periosteum.  The  elevator  is  then  pushed  beneath  the 
tendons  in  the  grooves  on  the  back  of  the  radius  and  the  tendons, 
sheaths,  and  ligaments  carefully  lifted  off  together  and  drawn  toward 
the  ulna.  The  hand  is  then  flexed,  the  proximal  row  of  carpal  bones 
removed,  beginning  with  the  scaphoid  and  the  trapezium  included  if 
necessary.  The  intercarpal  ligaments  should  always  be  cut  clean 
through.  The  distal  row  are  easily  approached  from  between  the 
trapezium  and  trapezoid.  The  thumb  is  abducted,  the  dorsal  ligaments 
of  the  carpometacarpal  joint  divided,  and  finally,  if  indicated,  the 
hand  is  adducted,  the  articular  ends  of  the  radius  and  ulna  protruded 
and  sawed  off.  Previous  to  this  the  lateral  ligaments  are  freed  sub- 
periosteally.  The  posterior  carpal  branch  of  the  radial  is  to  be  avoided. 
If  the  base  of  the  metacarpus  is  to  be  removed,  the  incision  is  prolonged 
somewhat  over  the  back  of  the  hand.  Occasionally  Hitter's  proposed 
drainage  by  counteropening  at  the  ulnar  side  may  be  used. 

Oilier,  who  prefers  partial  resection  or  excochleation  in  young  subjects 
according  to  the  extent  of  the  disease,  has  obtained  brilliant  results 
with  total  resection  in  adults.  He  uses  v.  Langenbeck's  incision  and 
adds  an  ulnar  incision  similar  to  Lister's.  Treves  has  expressed  himself 
as  an  advocate  of  Oilier 's  method.  Guided  by  the  experience  that  the 
radius  and  ulna  are  usually  uninvolved,  Konig  uses  v.  Langenbeck's 
incision,  but  separates  the  tendon-sheaths  only  slightly  from  the  dorsum 
of  the  radius,  saves  the  articular  cartilage  of  the  radius  as  far  as  possible, 
and  merely  removes  the  synovialis  radically  with  a  strong  sharp  double- 
spoon;  he  pries  out  the  proximal  row  of  soft  carpal  bones,  then  the 
distal  row,  leaving  the  pisiform  and  trapezium.    All  synovial  remnants 


382 


OPERATIONS  ON  THE  WRIST  AND  HAND. 


are  then  carefully  removed.  If  it  is  accessary  exceptionally  to  excise 
the  radio-ulnar  or  metacarpal  articular  surfaces,  Konig  uses  the  chisel, 
a  pointed  saw,  or  a  heavy  knife. 

Kocher's  Dorso-ulnar  Incision. — The  occasional  volar  subluxation  of 
the  hand  and  great  impairment  of  extension  following  v.  Langenbeck's 
operation  are  ascribed  by  Kocher  to  the  expected  functional  loss  of 
the  radial  extensors,  which  are  separated  from  their  insertions  on  the 
second  and  third  metacarpals.     He  therefore  uses  a  simple  dorso-ulnar 

Fig.  234. 


Incision  for  resecting  the  wrist: 


I.isfer; 


v.  Ltingenbeck; v.  Kocher. 


incision  about  3  inches  long,  similar  to  the  earlier  method  of  Chassaignac. 
(See  Fig.  234,  broken  line.) 

The  hand  is  slightly  abducted  and  the  skin  incision  carried  from 
the  middle  of  the  fifth  metacarpal  to  the  middle  of  the  wrist,  and  thence 
upward  in  the  middle  of  the  dorsal  surface  of  the  forearm.  At  the 
lower  end  the  basilic  vein  and  the  dorsal  cutaneous  branch  of  the  ulnar 
nerve  are  to  be  avoided.  After  dividing  the  fascia  and  the  annular 
ligament  the  tendon-sheaths  of  the  extensor  digiti  minimi  proprius  and 


RESECTION  OF  THE  WRIST  JOINT. 

extensor  communis  are  opened  at  the  metacarpophalangeal  joint,  the  ten- 
dons drawn  to  the  radial  side,  and  beneath  the  tendons  the  capsule 
incised  at  the  base  of  the  fifth  metacarpal,  at  the  unciform,  the  cuneiform, 
and  ulna.  The  capsule  is  then  separated  « » t V  toward  the  ulna  and  with  it 
the  attachment  of  the  tendon  of  the  extensor  carpi  ulnaris  at  the  base  of 
the  fifth  metacarpal.  Above,  the  tendon  is  drawn  out  of  the  groove  on  the 
ulna  and  the  capsule  pried  off  about  the  ulna.  If  the  radio-ulnar  joint 
is  involved,  the  disk  should  be  removed.  The  pisiform  is  left  with  the 
tendon  of  the  flexor  carpi  ulnaris  attached.  r\ 'he  capsule  is  freed  from 
the  fifth,  fourth,  and  third  metacarpals  on  the  flexor  side  and  on  the 
anterior  surface  of  the  radius,  the  attachment  of  the  tendon  of  the 
flexor  carpi  radialis  to  the  second  metacarpal  being  left  intact.  The 
capsule  on  the  dorsal  surface  of  the  lower  end  of  the  radius  is  then 
divided  as  far  as  the  extensors  of  the  thumb  and  the  tendons  lifted  out 
of  their  grooves.  The  tendons  of  the  extensors  are  left  intact  upon 
the  dorsal  surface  of  the  third  and  fifth  metacarpals.  The  hand  is 
dislocated  forcibly  by  abducting  and  flexing,  so  that  the  thumb  touches 
the  radial  side  of  the  forearm  and  the  extensor  tendons  lie  upon  the 
outer  side  of  the  radius.  The  capsule  on  the  outer  border  of  the 
radius  can  now  be  divided  and  the  attachment  of  the  supinator  longus 
lifted  off. 

Kocher  claims  as  the  advantage  of  this  method  that  the  division  of 
the  extensor  carpi  ulnaris  does  not  impair  extension  as  much  as  the 
division  of  the  two  radial  extensors;  further,  the  extensor  tendons  are 
not  so  liable  to  be  exposed  by  the  dorso-ulnar  incision  as  by  the  radial 
incision.  The  significance  of  damage  to  the  extensor  tendon  of  the 
little  finger  is  naturally  less  than  in  the  case  of  the  index  finger.  Further, 
the  unciform  process  of  the  unciform  is  more  easily  exposed  and  divided. 
On  the  other  hand,  Kocher  admits  that  the  trapezium  and  trapezoid 
are  less  accessible,  and  recognizes  the  advantage  of  the  dorsoradial 
incision  in  the  cases  in  which  the  disease  lies  chiefly  at  the  radial  side 
of  the  wrist.  A  plan  of  operation  accurately  mapped  out  with  reference 
to  the  anatomy  aids  the  subsequent  functional  result  of  resection  of 
the  wrist-joint. 

After  packing  or  draining  the  cavity  and  applying  sufficient  absorbent 
dressing  it  is  important  to  immobilize  the  hand  in  extension  upon  a 
splint.  Lister's  splint  fulfils  this  requirement.  The  extension  or  hyper- 
extension  position  is  preferable  because  it  usually  gives  a  much  better 
functional  result.  The  circular  plaster  splint  with  a  fenestrum  is  much 
used.  The  author  employs  an  anterior  moulded  plaster-strip  splint. 
The  fingers  should  always  be  left  free,  and  should  be  exercised  in  a 
few  days.  The  extension  position  may  be  maintained  with  advantage 
in  a  splint  for  some  time  after  complete  recovery  ffour  to  six  week> 
or  longer  (three  to  six  months)  because  in  a  number  of  cases  the  proper 
position  can  only  be  secured  in  this  way.  The  aesthetic  and  functional 
results  are  not  infrequently  surprisingly  favorable. 


384  OPERATIONS  ON  THE  WRIST  AND  HAND. 

RESECTION  AND   SEQUESTROTOMY  OF  THE  METACARPALS  AND 
PHALANGES  AND  THEIR  JOINTS. 

The  indication  for  resection  is  given  almost  exclusively  by  tuberculous 
myelitis  (or  periostitis),  whereas  septic  processes  may  call  for  seques- 
trotomv.     Conservative  treatment  is  indicated  in  the  case  of  wounds. 

If  the  surgeon  is  dealing  with  inflammatory  destruction  of  a  meta- 
carpal involving  the  head,  the  incision  is  made  directly  over  the  meta- 
carpophalangeal joint  and  to  the  ulnar  side  of  the  extensor  tendons. 
The  soft  parts,  including  the  tendons,  are  pushed  aside  with  the  elevator 
and  blunt  retractors  and  the  joint  incised.  The  head  and  then  the  entire 
metacarpal  is  freed  from  its  connections.  If  the  base  can  be  saved,  it 
is  of  advantage  for  the  protection  of  the  carpometacarpal  joint.  In  like 
manner  the  base  of  the  corresponding  first  phalanx  is  saved  if  possible. 
The  finger  recedes  upward  in  the  row  of  fingers  toward  the  carpus, 
but  may  retain  its  full  power.  The  preservation  of  the  head  of  the 
metacarpus  is  naturally  a  further  advantage.  The  after-treatment  is 
on  general  principles. 

To  excise  a  phalanx,  the  incision  is  made  to  the  side  of  the  extensor 
tendons,  but  should  avoid  the  vessels  and  nerves.  To  prevent  secondary 
lateral  (ulnar  or  radial)  deviation,  it  is  of  advantage  to  make  a  bilateral 
incision.  Excision  with  knife  and  elevator  and  the  after-treatment  are 
simple.  A  splint  should  be  worn  for  some  time  to  prevent  lateral  deformity. 

Sequestrotomy  of  a  metacarpal  usually  requires  a  similar  procedure, 
chiselling  off  of  the  dorsal  covering  and  widening  of  the  bone  cavity 
as  in  every  other  sequestrotomy.  In  the  phalanx,  as  the  process  is 
usually  recent  and  the  new  formation  of  bone  soft,  a  single  longitudinal 
incision  is  usually  sufficient  to  expose  the  sequestrum.  Sequestra  occur 
chiefly  in  the  end-phalanges,  and  their  extraction  here  is  one  of  the 
simplest  surgical  operations. 

Resection  of  the  metacarpophalangeal  and  interphalangeal  joints 
may  be  required  to  check  a  septic  or  tuberculous  process  and  to  restore 
the  best  possible  function;  this  latter  aim  is  not  usually  attained  if  one 
of  the  adjacent  bones  is  involved  to  any  extent.  If  possible,  one  of  the 
joint-surfaces  should  be  saved.  Even  if  both  are  sacrificed,  however, 
a  certain  amount  of  mobility  may  be  preserved. 

Resection  of  the  metacarpal-head  for  irreducible  dislocation  of  the 
thumb,  an  operation  rarely  required,  was  performed  by  the  author 
in  one  instance  with  a  very  satisfactory  result. 

The  incision  to  resect  the  joint  should  not  be  too  small  to  allow  full 
inspection  and  thorough  technic:  for  an  adult  metacarpophalangeal 
joint  not  less  than  \\  inches,  for  an  interphalangeal  joint  not  under 
1  inch.  The  tendons,  nerves,  and  vessels  are  to  be  avoided  the  same 
as  in  resection  of  the  bone,  namely,  by  an  incision  at  the  side  of  the 
extensor  tendons.  The  joint  is  then  opened,  all  diseased  tissue  removed, 
and  the  wound  packed  and  partly  closed.  A  smaller  or  larger  section 
of  the  adjacent  bone  may  be  removed  through  the  same  incision,  if 
desirable,  by  means  of  Liston's  cutting  bone-forceps  or  Luer's  rongeur- 
forceps.     In  a  large  number  of  cases  the  final  result  is  good. 


MALFORMATIONS,  INJURIES,  AND  DISEASES 
OE  THE  HIE  AND  THIGH. 


l'.v   Prop.  Dr.  A.  HOFI  A. 


MALFORMATIONS,  INJURIES,  AND  DISEASES  OF 

THE  HIP. 


Anatomy  and  Physiology. — The  hip  corresponds  to  the  articulation 
of  the  pelvis  with  the  lower  extremity.  The  hip-joint  is  composed  of 
the  acetabulum  of  the  os  innominatum  and  the  head  of  the  femur. 
The  acetabulum,  formed  by  the  ilium,  ischium,  and  os  pubis,  is  a 
hemispherical  cavity  adapted  to  receive  the  head  of  the  femur  by  the 
deposit  of  a  thick,  sharp-edged,  fibrocartilaginous  ring  upon  its  free 
border  (the  cotyloid  cartilage).  At  the  anterior  lower  margin  there  is 
a  bridged  gap,  the  cotyloid  notch.  The  cavity  is  covered  with  cartilage 
only  where  the  cotyloid  ligament  is  attached,  the  floor  being  covered 
merely  with  synovial  membrane  and  containing  a  certain  amount  of 
loose  adipose  tissue. 

The  articular  head  of  the  femur  is  nearly  hemispherical,  being  slightly 
flattened.  The  cavity  and  head  therefore  do  not  fit  exactly,  so  that  the 
surfaces  are  not  in  contact  throughout  in  all  positions  of  the  extremity. 
Slightlv  below  the  summit  of  the  head  the  ligamentum  teres  is  attached 

O  t  c 

in  a  slight  depression,  its  fibres  merging  in  part  immediately  into  the 
hyaline,  cartilaginous  covering  of  the  articular  surface.  The  head  is 
connected  by  its  neck  to  the  shaft  of  the  femur,  the  junction  being 
indicated  by  the  intertrochanteric  line  between  the  greater  and  lesser 
trochanters. 

In  the  newborn  the  upper  end  of  the  femur  is  like  that  of  the  humerus, 
the  articular  cartilage  resting  like  a  cap  upon  the  shaft  of  the  bone. 
The  first  primary  centre  forms  in  the  head  at  the  end  of  the  first  year. 
The  trochanter  major  forms  in  the  second  year.  In  the  fourth  year 
begin  the  ossification  of  the  greater  trochanter  and  its  demarcation  from 
the  cartilage  of  the  head.  The  demarcation  is  complete  at  the  sixth 
year.    (Konig.) 

The  capsule  of  the  joint  with  reference  to  its  breadth  is  the  reverse 

of  that  of  the  shoulder-joint,  the  latter  being  narrower  at  its  insertion 

on  the  scapula    than  at  its  attachment  on  the  humerus,  whereas  the 

former  is  narrower  at  the  femur  than  at  the  acetabular  margin,  and 

Vol.  III.— 25  (385) 


386     MALFORMATIONS,  INJURIES  AXD  DISEASES  OF  THE  HIP. 

so  represents  a  cone  the  point  of  which  is  directed  downward,  the  base 
upward.  It  arises  from  the  entire  circumference  of  the  cavity,  but  is 
not  attached  all  around  the  neck  of  the  femur,  but  only  on  the  front 
and  sides,  especially  on  the  intertrochanteric  line.  Its  posterior  wall 
is  not  immediately  connected  with  the  hone,  but  ends  in  a  sharply 
defined,  free  border  from  which  the  synovial  membrane  is  continued 
on  over  the  neck  of  the  femur.  (Fig.  235.)  The  wall  of  the  capsule 
varies  in  thickness  and  firmness,  the  weakest  parts  being  behind  at 
the  lower  border  where  the  synovial  membrane  passes  over  on  to  the 

Fig.  235. 


Fmntal  section  through  the  hip-joint  of  an  eieht-year-old  hoy.  U,  cross-section  of  the  ilium; 
c,  cartilaginous  disk  between  the  pubis  and  ischium;  pu,  cross-section  of  the  descending  ramus  of 
the  pubis,  attached  to  the  above  cartilage  by  the  upper  margin  of  the  obturator  membrane; 
tg,  cotyloid  cartilage;  ta,  tran.-ver>e  ligament  of  acetabulum;  '/■•>.  zona  orbicularis  of  the  joint 
capsule;   ctmj,  epiphysis  of  the  great  trochanter;  If.  ligamentum  teres  femoris.     (v.  Bruns.) 


neck  of  the  femur.  In  front  there  are  reinforcing  bands,  the  most  im- 
portant of  which  is  the  iliofemoral  ligament,  or  ligament  of  Bertini 
(Fig.  235),  arising  \  inch  in  width  from  the  anterior  inferior  spine  of  the 
ilium  and  attaining  a  width  of  3  inches  as  it  diverges  into  two  arms 
to  be  attached  to  the  intertrochanteric  line.  It  was,  therefore,  called  the 
Y-ligament  by  Bigelow,  who  recognized  its  important  influence  upon 
the  form  and  reduction  of  dislocations  of  the  hip-joint.  The  trunk  of 
the  Y  is  often  very  short  if  the  division  of  the  inner  and  outer  arms 


MALFORMATIONS,  INJURIES  AND  DISEASES  OF  THE  HIP.     ;;,s7 


Fig   236. 


begins  a  short  distance  from  its  origin.  These  arms  merge  into  the  rest 
of  the  capsule  without  any  sharp  demarcation,  but  not  with  all  their 

fibres,  as  lateral  bundles  run  around  both  sides  of  the  neck  to  unite 
behind  and  form  a  girdle,  the  zona  orbicularis,  encircling  the  neek 
somewhat  as  the  annular  ligament  surrounds  the  head  of  the  radius. 
Tin-  Y-ligament  is  extremely  strong  and  resistant.  In  thickness  it 
exceeds  the  patellar  ligament  and  the  tendo  Aehillis.  In  a  well-developed 
man   1  1(H)  pounds  are  required  to  tear  it. 

The  two  other  reinforcing  bands  of  the  capsule,  the  pubofemoral 
and  ischiocapsular  ligaments,  are  less  firm,  the  former  running  from 
the  pubic  spine  to  the  lesser  trochanter,  the  latter  from  the  tuber  ischii 
to  the  posterior  wall  of  the  capsule. 
The  ligamentum  teres,  running  from 
the  cotyloid  notch  to  the  head  of  the 
femur  conveys  the  nutrient  vessels 
to  the  latter.  That  the  contact  be- 
tween head  and  cavity  is  not  over- 
come by  the  weight  of  the  limb  is 
clue  to  external  air  pressure,  as 
demonstrated  by  the  experiments  of 
the  Weber  brothers.  In  the  living 
subject  there  are  in  addition  the 
valve  action  of  the  cotyloid  cartilage, 
the  cohesion  of  the  synovialis,  and 
the  influence  of  the  muscles  covering 
the  hip-joint.  Of  the  latter,  the 
adductors,  the  pectineus,  and  the 
gracilis  lie  to  the  inner  side  of  the 
joint;  the  iliopsoas,  sartorius,  rectus 
femoris,  and  tensor  fasciae  lata?  in 
front;  the  glutei,  pyriformis,  obtur- 
ator interims,  with  the  gemelli, 
quadratus  femoris,  and  obturator 
extemus,  to  the  outer  side;  and 
behind,  the  biceps,  semitendinosus, 
and  semimembranosus. 

These  strong,  reinforcing  soft  parts  together  form  a  wall  which  make 
the  joint  extremely  inaccessible  to  palpation,  especially  if  covered  in 
addition  with  a  well-developed  cushion  of  fat.  Nevertheless  the  position 
of  the  hip-joint  can  be  determined  from  without  with  approximate 
accuracy.  In  children  a  plane  passing  horizontally  through  the  tip  of 
the  great  trochanter  about  touches  the  highest  point  on  the  head  of  the 
femur.  In  adults  the  trochanter  lies  somewhat  lower,  so  that  the  same 
plane  passes  through  the  middle  of  the  head.  If  the  femur  is  slightly 
flexed,  the  tip  of  the  great  trochanter  lies  in  a  line  drawn  from  the 
anterior  superior  spine  to  the  tuber  ischii  ( Roser-Xclaton's  line,  Fig.  237). 
If  the  trochanter  cannot  be  felt  on  account  of  swelling,  the  position  of 
the  joint  can  be  determined  accurately  by  erecting  a  perpendicular  at 


Iliofemoral  ligament;  Y-ligament  of  Bigelow. 


388     MALFORMATIONS,  INJURIES  AND  DISEASES  OF  THE  HIP. 

the  middle  of  a  line  drawn  between  the  anterior  superior  spine  and  the 
symphysis;  tins  line  divides  the  joint  approximately  into  two  equal 
parts.     (Konig. 

The  hip-joint,  like  the  shoulder-joint,  is  a  free  arthrodia.  Its  move- 
ments are  possible  in  all  conceivable  directions  in  any  axis  passing 
through  the  middle  of  the  head.  The  movements  are  divisible  into  those 
about  three  principal  axes  from  which  all  the  others  can  be  combined: 
1.  Those  about  a  frontal  axis  drawn  transversely  through  both  heads 
of  the  femurs,  flexion  and  extension.  2.  Those  about  a  sagittal  axis 
drawn  perpendicular  to  the  former,  abduction  and  adduction.  3.  Those 
about  a  vertical  axis  coincident  with  that  of  the  femur,  inward  and 
outward  rotation.  Under  normal  conditions  abduction  and  adduction 
are  widest,  flexion  and  extension  less  so,  rotation  least  ample. 

Fig.  237. 


The  Roser-X^ls 


Each  of  these  movements  has  its  physiological  limitation.  Flexion  is 
usually  limited  by  the  contact  of  the  soft  parts  of  the  thigh  with  those 
of  the  abdomen.  In  very  thin  individuals  with  marked  kyphosis  the 
neck  of  the  femur  may  strike  against  the  upper  rim  of  the  acetabulum. 
Extension  is  limited  by  the  iliofemoral  ligament;  the  latter  also  checks 
save  movements  about  both  other  axes,  the  outer  arm  limiting 
adduction  and  outward  rotation,  the  inner  arm  and  the  pubofemoral 
ligament  limiting  abduction  and  inward  rotation,  the  action  of  both 
arms  of  the  ligament  being  increased  by  extension.  Abduction,  adduc- 
tion,  and  rotation  are  therefore  greater  if  the  thigh  is  flexed.  The 
mobility  of  the  thigh  depends  further  upon  the  suppleness  and 
reciprocal  relation  of  the  muscles,  as  demonstrated  by  the  litheness 
of  contortionist-. 


CHAPTER   XXII. 

MALFORMATIONS  OF  THE  HIP-JOINT. 

CONGENITAL  DISLOCATION  OF  THE  HIP-JOINT. 

Congenital  dislocation  of  the  hip-joint  is  the  most  frequent  of  all 
inherited  dislocations.  According  to  Kronlein,  in  addition  to  the  90  cases 
of  hip  dislocations  seen  in  the  Berlin  surgical  polyclinic  there  were  only 
5  of  the  humerus,  2  of  the  head  of  the  radius,  and  1  of  the  knee-joint. 
The  author's  statistics  of  the  frequency  of  congenital  dislocation  of  the 
hip  compared  to  other  surgical  diseases  give  the  following:  in  10,000 
surgical  patients  there  were  7  of  these  cases  (0.07  per  cent);  in  1444 
cases  of  deformity  there  were  7  congenital  hip  dislocations  (0.49  per 
cent.).  The  affection  appears  to  vary  in  different  geographical  areas, 
being  quite  frequent  in  some  countries,  rare  in  others.  Of  898  cases 
observed  by  various  authors,  105  were  in  males  (12  per  cent.)  and  793 
in  females  (88  per  cent.).  The  deformity  is  therefore  seven  times  more 
frequent  in  females  than  in  males.  It  is  more  often  unilateral  than 
bilateral:  576  unilateral  to  322  bilateral.  In  the  unilateral  form  the 
left  side  is  involved  somewhat  more  frequently  than  the  right.  There 
does  not  seem  to  be  any  sexual  predisposition  to  this  or  that  form  of 
dislocation,  as  emphasized  by  Kronlein  against  the  poorly  founded 
assertion  of  Gueniot. 

Etiology. — Numerous  theories  are  advanced  in  regard  to  the  causation 
of  congenital  dislocation  of  the  hip: 

1.  The  so-called  congenital  dislocation  is  of  a  traumatic  nature,  and  is 
due  to  external  violence  affecting  the  uterus  during  pregnancy  (Hippoc- 
rates, A.  Pare,  Cruveilhier)  or  to  forcible  traction  upon  the  foot  during 
delivery  (Capuron,  Chelius,  d'Outrepont,  J.  L.  Petit,  Phelps,  Brod- 
hurst).  Disregarding  the  fact  that  in  the  author's  experience  fracture 
is  more  liable  to  be  produced  than  dislocation  by  such  an  injury,  this 
theory  is  untenable  because  in  the  large  majority  of  cases  there  is  no 
history  of  such  trauma. 

2.  The  dislocation  is  pathological,  and  is  due  either  to  weakening  and 
relaxation  of  the  ligaments  of  the  joint  (Sedillot,  Stromeyer),  to  an  intra- 
uterine inflammation  of  the  joint,  hydrops  of  the  joint  (Parise),  fungous 
synovitis  with  effusion  (Verneuil,  Broca,  Pfender),  or  caries  of  the  joint 
and  destruction  of  the  capsule  (Morel-Lavallee,  Albers,  v.  Ammon). 
Although  intrauterine  inflammation  of  the  joint  certainly  occurs,  it  is 
not  responsible  for  the  dislocation,  as  there  is  usually  an  absence  of  any 
sign  of  previous  inflammation  in  congenital  dislocation. 

(  389  ) 


390  MALFORMATIONS  OF  THE  HIP-JOINT. 

3.  The  dislocation  is  due  to  the  peculiar  position  of  the  lower  extrem- 
ities in  utero:  (a)  Dupuytren  thinks  it  is  possible  that  if  the  tissues  are 
abnormally  yielding,  the  pressure  of  the  head  against  the  posterior 
inferior  part  of  the  capsule,  as  induced  by  a  strongly  flexed  position  of 
the  thigh,  may  occasionally  cause  the  dislocation.  (6)  Roser  ascribes 
the  dislocation  to  abnormal  adduction  of  the  thigh  resulting  from  the 
pressure  due  to  insufficient  amniotic  fluid,  (c)  Lorenz  believes  that 
a  gradual  stretching  of  the  capsule  takes  place  with  simultaneous  prying 
out  of  the  head  from  the  cavity  under  the  influence  of  constant,  excessive 
flexion  and  adduction  of  the  thigh.  The  departure  of  the  head  causes 
atrophy  of  the  cavity,  although  the  head  still  lies  opposite  the  cavity 
and  is  merely  lifted  away  from  it.  The  displacement  of  the  head  upward 
results  secondarily  after  birth  from  the  traction  of  the  muscles  and  the 
body-weight,  (d)  Schanz  conceives  that  with  insufficient  amniotic  fluid 
the  continuous  elastic  pressure  of  the  wall  of  the  uterus  forces  the  flexed 
and  adducted  head  out  of  the  cavity.  The  same  pressure  is  supposed 
to  produce  the  typical  deformity  of  the  femur,  (e)  Hirsch  believes 
that  in  addition  to  the  pressure  due  to  insufficient  amniotic  fluid  there 
is  a  further  dislocating  force,  namely,  the  power  of  growth  of  the  foetal 
femur.  By  this  inherent  physiological  power  the  femur  is  supposed  to 
grow  beyond  the  cavity. 

4.  The  dislocation  is  due  to  muscular  retraction,  which  in  turn  is 
due  to  a  change  in  the  central  nervous  system.  (Guerin.)  Guerin  is 
right  about  the  muscular  retraction,  but  advanced  this  theory  for  the 
sake  of  his  tenotomy.  The  retraction  does  take  place,  but  is  not  the 
cause  but  rather  the  result  of  the  deformity,  as  will  be  discussed  fully 
under  the  pathological  anatomy. 

5.  The  dislocation  is  due  to  intrauterine  paralysis  of  the  muscles 
running  from  the  pelvis  to  the  great  trochanter.  The  paralysis  is 
gradually  followed  by  relaxation  of  the  ligaments,  and  this  in  turn  by 
the  dislocation,  especially  later  when  the  child  begins  to  walk  and 
support  the  body-weight.  (Verneuil.)  It  is  true  that  such  muscular 
paralyses  result  from  spinal  disease  in  infancy,  but  the  resulting  dislo- 
cation is  not  to  be  designated  as  congenital  but  as  paralytic ;  it  will  be 
described  in  a  separate  section. 

6.  The  dislocation  is  referable  to  maldevelopment  preventing  the 
formation  of  the  normal  articular  surfaces,  v.  Amnion  states  that  it  is 
due  to  arrestment  at  an  early  period  of  foetal  life.  v.  Ammon's  theory 
was  later  substantiated  and  strengthened  by  a  series  of  studies  under- 
taken to  learn  more  of  the  nature  of  the  inhibition.  (Dollinger,  Grawitz, 
Holzmann,  Lannelongue.)  According  to  Dollinger,  the  arrestment  is 
due  to  an  early  ossification  of  the  Y-shaped  cartilage  of  the  cavity  or  to 
an  insufficient  production  of  bone  from  this  cartilage.  Grawitz  recog- 
nizes only  the  latter  cause.  Holzmann  regards  a  primary  arrestment  in 
the  development  of  the  cavity  as  the  cause.  Lannelongue  recently  ad- 
vanced the  theory  that  the  malformation  of  the  cavity  is  of  central  origin. 

A  chain  of  evidence  is  produced  in  support  of  the  theory  of  malforma- 
tion, namely,  that  the  dislocation  is  frequently  accompanied  by  other 


CONGENITAL  DISLOCATION  OF  THE  HIP-JOINT.  3<jl 

malformations,  frequently  bilateral  dislocations;  further,  simultaneous 
dislocation  of  Other  joints;  and  finally,  that  heredity  may  be  a  cause, 
ECronlein,  Lorenz,  and  Delanglade  citing  entire  families  in  which  sisters 
and  relatives  presented  the  deformity.  Personally  the  author  has 
frequently  seen  instances  of  this  kind. 

Clearness  has  been  broughl  into  the  discussion  of  the  etiology  by  the 
.r-ray.  It  shows  what  the  author  has  always  emphasized  on  the  grounds 
of  his  open  operations  for  the  dislocation,  namely,  that  there  is  not 
aplasia,  but  rather  hyperplasia  of  the  tissues  in  the  cavity,  the  latter 
always  appearing  considerably  thickened.  Further,  it  shows  very  clearly 
a  condition  which  to  his  mind  is  positive  evidence  that  the  congenital 
dislocation  is  due  to  a  vitium  primoe  formationis,  namely,  that  in  25  per 
cent,  of  the  cases  which  are  regarded  clinically  as  absolutely  unilateral 
there  are  changes  present  in  the  other  hip-joint,  a  fact  which  he  dis- 
covered and  which  was  published  by  Bade;  sometimes  there  is  distinct 
flattening  of  the  upper  margin  of  the  cavity,  and  in  other  instances 
changes  in  the  form  and  direction  of  the  sound  head  of  the  femur. 
Recently  Friedlander  reported  the  fact  that  there  was  an  excessive 
growth  of  the  femur  which  he  regarded  as  the  cause;  a  lordotic  position 
of  the  spine  was  supposed  to  diminish  the  physiological  inhibition  of 
growth  and  thus  lead  to  excessive  curvature  of  the  femur  in  the  sense 
of  the  deformity  found  in  dislocation  of  the  hip. 

The  greater  frequency  of  the  dislocation  in  females  is  directly  con- 
nected with  the  difference  in  structure  of  the  female  and  male  pelvis. 
Fehling  demonstrated  that  the  acetabulum  of  the  female  foetus  faced 
more  to  the  side  than  that  of  the  male,  the  latter  facing  more  forward. 
So  it  is  easy  to  understand  how,  for  example,  with  insufficient  liquor 
amnii,  the  constant  elastic  pressure  of  the  uterine  wall  might  force  the 
head  of  the  femur  out  of  the  cavity  more  easily  in  the  female  than  in 
the  male.  Tillmanns  would  refer  this  predisposition  to  dislocation  in 
the  female  to  the  more  vertical  position  of  the  os  innominatum,  but  this 
factor  applies  only  to  the  later  progress  of  the  dislocation  after  birth. 
The  conditions  favoring  dislocation  are  certainly  present  at  an  earlier 
period  than  the  vertical  position  of  the  os  innominatum.  The  original 
well-known  view  of  Roser,  that  the  external  male  genitals  prevented 
any  pronounced  adduction  of  the  limbs  in  utero,  is  entirely  untenable. 

Pathological  Anatomy. — Before  taking  up  the  changes  occurring  in  con- 
genital dislocation  of  the  hip-joint  the  surgeon  should  understand  clearly 
the  position  of  the  head  of  the  femur.  Earlier  it  was  generally  conceived 
that  the  head  left  the  cavity  in  a  direction  upward  and  backward,  and, 
separated  from  it  by  the  capsule,  came  to  lie  immediately  in  front  of 
the  great  sciatic  notch. 

In  recent  years  surgeons  have  learned  that  this  view  is  wrong.  Based 
upon  pathologico-anatomical  and  accurate  clinical  observations,  par- 
ticularly with  the  aid  of  the  .r-ray,  it  has  been  found  that  the  position 
of  the  dislocated  head  is  usually  different  from  what  it  was  formerly 
supposed.  The  cases  previously  designated  as  partial  dislocations  were 
found  in  fact  to  be  dislocations  in  which,  however,  the  displacement  of 


392 


MALFORMATIONS  OF  THE  HIP- JOINT. 


the  head  was  slight.  The  author  stated  that  in  unilateral  dislocation 
the  cavity  on  the  apparently  sound  side  showed  changes  chiefly  at  the 
upper  margin,  as  in  the  genuine  dislocation.  This  explains  the  cases  in 
which  there  was  at  first  no  recognizable  dislocation,  but  in  which  it 
appeared  later  as  the  result  of  the  body-weight. 

Dislocation  Directly  Upward. — In  the  newborn  the  position  of 
the  head  varies;  in  the  majority  of  cases  it  is  above  or  above  and  slightly 
behind  the  cavity.  In  young  children  the  head  is  usually  found  directly 
above  the  cavity,  so  that  the  primary  congenital  dislocation  of  the 
femur  is  upward  and  forward.  (Kolliker,  Hoffa,  Lange.)  So  as  the 
first  type  there  is  a  dislocation  of  the  head  of  the  femur  directly  upward 
(Fig.  23S)  (luxatio  supracotyloidea). 


Fig.  23S. 


Position  of  the  head  of  the  femur  in  congenital  dislocation  of  the  hip,  first  type.     (Hoffa.) 

Dislocation  Upward  and  Outward. — As  a  rule  the  head  does  not 
remain  directly  above  the  cavity,  but  lies  more  above  and  outward, 
apparently  from  the  action  of  the  muscles  and  body-weight.  If  the 
dislocation  is  bilateral,  the  same  condition  is  usually  found  on  both  sides. 
So  the  second  type — and  this  comprises  by  far  the  greater  majority  of 
cases — is  the  one  in  which  the  dislocated  head  lies  above  and  to  the 
outer  side  of  the  cavity  (Fig.  239)  (luxatio  supracotyloidea  et  iliaca). 

Iliac  Dislocation. — As  the  child  grows  older  the  head  may  remain 
in  the  above  position.  This  is  only  possible,  however,  if  the  head  is 
very  much  flattened  (luxatio  subspinosa,  Schede).     As  a  rule,  under 


COXdEXITAL  DISLOCATION  OF  THE  HIP  JOINT. 


393 


the  influence  of  the  body-weight  and  the  action  of  the  muscles,  the  head 
advances  higher,  but  may  not  necessarily  be  greatly  displaced  behind 


Position  of  the  head  of  the  femur  in  congenital  dislocation  of  the  hip,  second  type.     (Hoffa.) 

Fig.  240. 


Position  of  the  head  of  the  femur  in  congenital  dislocation  of  the  hip,  third  type.     (Hoffa.) 

the  ilium.     It  then  lies  to  the  outer  side  of  the  anterior  superior  spine. 
On  hyperextending  the  limb  one  can  feel  the  round  surface  of  the  head 


394  MALFORMATIONS  OF  THE  HIP-JOIXT. 

through  the  soft  parts  at  the  side  of  the  spine.  If  the  limb  is  flexed, 
adducted,  and  rotated  slightly  inward,  the  head  can  he  felt  gliding 
backward.  There  is  then  a  genuine  luxatio  iliaca,  the  third  type. 
(Fig.  240.)  These  cases  constituted  the  larger  majority  of  those  brought 
to  the  author  for  examination. 

Sciatic  Dislocation". — The  fourth  type  is  the  genuine  luxatio 
ischiadica,  in  which  the  head  advances  behind  the  ilium  so  that  it  is 
not  recognizable  in  the  x-ray.  It  lies  immediately  at  the  side  of  the 
great  sciatic  notch  upon  the  ilium. 

There  are  therefore  approximately  four  types  to  be  distinguished 
according  to  the  position  of  the  dislocated  head.  The  older  the  child 
the  more  the  first  type  approaches  the  fourth,  although  a  pronounced 
iliac  dislocation  is  a  great  rarity  in  infants  up  to  the  first  year.  The 
cause  of  the  gradual  transit  of  the  head  from  above  and  to  the  outer 
side  to  above  and  behind  is  unquestionably  to  besought  in  the  action 
of  the  weight  of  the  body  and  of  the  muscles. 

Pathological  Changes. — The  changes  found  in  the  affected  joint  vary 
gradually,  to  a  certain  extent,  with  the  age  of  the  patient.  The  following 
description  is  from  the  author's  findings  in  about  200  operations  and  the 
articles  of  \  alette,  Lorenz,  Delanglade,  Lange,  and  Schede. 

In  the  newborn  the  changes  in  and  about  the  joint  are  relatively 
slight.  The  cavity  is  never  absent  and  always  has  its  proper  position. 
Its  form,  however,  is  always  slightly  changed.  It  is  usually  atrophied, 
narrower,  and  more  elongated  than  the  normal  cavity.  The  normal  arch 
of  the  posterior  margin  is  often  absent  and  the  floor  is  sometimes  filled 
with  adipose  or  fibrous  tissue.  (Paletta,  Parise. )  In  like  manner  the  head 
of  the  femur  shows  slight  changes  at  the  time  of  birth.  It  is  sometimes 
thick,  rounded,  and  without  any  distinct  constriction  at  the  neck,  or 
elongated  or  conical  like  a  sugar-loaf.  Even  if  atrophied,  it  is  always 
larger  than  its  joint-cavity.  (Cruveilhier,  Houel,  Porto.)  Even  at  this 
period  it  is  always  somewhat  anteverted,  although  slightly;  or  it  is  in 
the  sagittal  plane  and  more  or  less  depressed  compared  to  the  tip  of 
the  great  trochanter.  The  ligamentum  teres  is  usually  present  as  a  flat 
band  3,  4,  to  4.5  inches  long.  The  capsule  is  normal,  also  the  pelvis. 
Verneuil,  in  unilateral  dislocation  of  a  newborn  infant,  found  the 
muscles  about  the  dislocated  joint  shorter  and  less  developed  than  on 
the  other  side.  Lannelongue  found  the  muscles  atrophic  but  without 
a  trace  of  degeneration,  the  atrophy  involving  all  the  muscles  of  the 
limb. 

In  childhood  the  changes  are  different  from  the  time  the  child  begins 
to  walk.  The  cavity  does  not  grow  as  rapidly  as  the  other  bones,  and 
so  is  relatively  smaller  and  usually  more  triangular  in  form.  (Fig.  241.  ■ 
The  connective  tissue  on  the  floor  hypertrophies  and  so  raises  it;  exos- 
toses are  also  supposed  to  develop  frequently.  (Porto.)  In  every  case 
the  acetabulum  is  considerably  thickened,  so  that  it  would  appear  as 
if  the  affected  parts  of  the  pelvis  increased  in  thickness  as  the  result  of 
the  inhibition  of  growth  in  length  and  breadth.  The  cotyloid  cartilage 
is  usually  developed,  lying  like  a  valve  upon  the  cavity  or  projecting 


CONGENITAL  DISLOCATION  OF  THE  HIP-JOINT. 


395 


distinctly,  especially  at  the  anterior  margin.  At  this  time  the  formation 
of  a  new  cavity  is  supposed  to  be  evident  above  the  old  one.  The  author 
has  never  met  with  a  pronounced  form  of  such,  but,  on  the  other  hand, 
has  repeatedly  seen  a  projection  upward  of  the  old  cavity,  a  sort  of 
sliding  groove  in  which  the  head  had  advanced  upward. 

The  head  of  the  femur,  separated  from  the  old  cavity,  lies  either 
directly  above  it,  or  more  frequently  above  and  to  the  outer  side,  or 
above  and  behind  upon  the  ilium.  It  is  flattened  on  the  side  resting 
against  the  pelvis.  In  young  children  the  surface  of  the  head  is  usually 
smooth  and  normal;  in  older  patients  it  is  often  uneven  and  rough. 
The  neck  of  the  femur,  which  is  usually  well  preserved  during  the  first 
few  years,  atrophies  with  increasing  years,  so  that  finally  it  is  only 

Fig.  241. 


Congenital  dislocation  of  the  hip  (child  seven  years  old). 


rudimentary.  At  the  same  time  its  direction  is  always  changed,  so  that 
it  bends  horizontally  forward  (Schede,  Lorenz,  Hoffa)  and  lies  not  in 
a  frontal,  but  rather  in  a  sagittal  plane.  This  deviation  is  usually  called 
anteversion.  As  correctly  stated  by  Lange,  the  neck  of  the  femur  is 
not  really  bent  forward,  but  the  whole  upper  end  of  the  femur  has  been 
twisted  about  its  long  axis,  so  that  while  the  upper  end  lies  more  or 
less  in  the  sagittal  plane,  the  axis  of  the  condyles  points  approximately 
as  in  a  normal  limb.  The  foot  has  almost  its  normal  position,  and  not 
that  of  maximal  outward  rotation  as  one  would  expect  from  the  sagittal 
position  of  the  neck  of  the  femur. 

The  capsule  is  dense,  very  thick,  and  usually  somewhat  dilated,  so 
that  the  head  has  a  greater  range  of  motion.  It  is  attached  to  the 
acetabular  margin,  surrounds  the  head  on  all  sides,  and  is  applied 


396 


MALFORMATIONS  OF  THE  HIP- JOIST. 


Fig.  242. 


around  the  neck  close  to  the  edge  of  the  cartilage.  There  are  usually 
some  fibrous  adhesions  extending  from  the  attachment  of  the  capsule 
upward  on  the  cartilage. 

The  ligamentum  teres  undergoes  various  changes.  In  200  cases  of 
the  author  it  was  entirely  absent  in  54;  it  was  present  in  146,  and 
when  present  was  always  well  developed  and  elongated,  so  that,  for 
example,  in  a  girl  one  and  one-half  years  old  it  had  attained  a  length  of 
1.5  inches  and  a  thickness  of  4  mm.     (Fig.  242.)     It  is  remarkable  that 

the  ligament  is  more  rarely  absent 
in  unilateral  than  in  bilateral  dislo- 
cations. The  pelvis  may  show  pro- 
nounced changes.  In  a  case  of  left- 
sided  congenital  dislocation  in  a 
female  infant  six  months  old,  Till- 
manns  found  an  asymmetry  of  the 
pelvis  and  a  left  lumbar  scoliosis. 

The  changes  in  the  muscles  are 
characteristic.  Surgeons  are  in- 
debted to  Lorenz  for  recent  addi- 
tional knowledge  in  regard  to  these 
changes,  formerly  correctly  described 
by  Pravaz  and  Dupuytren.  The 
muscles  not  only  atrophy,  but  are 
also  altered  in  length  and  direction. 
Generally  all  the  muscles  are  in- 
volved whose  course  corresponds 
with  the  direction  of  displacement  of  the  head,  being  shortened  in  propor- 
tion to  the  elevation  of  the  head,  whereas  the  muscles  are  lengthened 
whose  direction  is  at  right  angles  to  the  axis  of  the  femur.  So  the  per- 
trochanteric muscles,  namely,  those  running  from  the  pelvis  to  the  tro- 
chanter, generally  show  shortening,  the  pelvifemorals  are  lengthened,  and 
the  pelvicrural  muscles  are  more  or  less  shortened.  Of  the  pertrochan- 
teric muscles,  the  gluteus  maximus  especially  shows  shortening  and 
change  in  the  direction  of  its  fibres.  The  latter,  instead  of  running 
sharply  downward  and  outward,  are  inclined  only  gently  downward  and 
outward.  If  the  dislocation  is  marked,  they  may  run  horizontally.  The 
gluteus  medius  undergoes  a  marked  change  in  position,  the  anterior  por- 
tion, running  normally  upward  and  forward  to  the  anterior  part  of  the 
crest  of  the  ilium,  now  appearing  to  lie  in  a  horizontal  plane,  whereas 
the  posterior  portion  completely  bridges  over  the  head  of  the  femur  and 
runs  correspondingly  horizontal  outward  from  its  surface  of  origin  on  the 
ilium.  As  in  this  manner  the  muscle  is  stretched  over  the  head,  it  is 
really  lengthened  rather  than  shortened.  The  gluteus  minimus  loses 
its  normal  vertical  position  entirely,  lies  in  a  horizontal  plane,  and  is 
somewhat  shortened  like  the  medius.  The  pyriformis  runs  upward 
instead  of  downward,  and  the  obturators,  gemelli,  and  quadratus  run 
upward  instead  of  horizontally;  all  these  muscles  are  lengthened.  The 
iliopsoas  runs  downward  and  outward  on  the  anterior  wall  of  the  pelvis. 


Hypertrophied  ligamentum  teres  in  congenital 
dislocation. 


CONGENITAL  DISLOCATION  OF  THE  HIP  JOINT. 


397 


Its  tendinous  end  is  thereby  turned  upward  and  backward  and  stretched. 
Where  the  muscle  runs  over  the  edge  of  the  anterior  wall  of  the  pelvis 
a  deep  sliding  groove  is  made  in  the  latter,  as  described  by  Dupuytren. 
The  iliopsoas  represents,  as  Lorenz  expresses  it,  a  tight-rope,  stretched 

between  the  anterior  surface  of  the  spinal  Column  and  the  dislocated 
lesser  trochanter,  and  supports  the  pelvis  from  beneath  like  a  sling. 

( )f  the  pelvifemoral  muscles, the  upper  portion  of  the  adductor  magnus 
is  lengthened,  the  lower  portion  is  shortened,  so  that  the  upper  portion 
instead  of  running  horizontally  runs  upward,  the  lower  fibres  being  dis- 
placed in  the  direction  of  the  axis  of  the  femur.  The  adductor  longUS 
and  brevis  show  an  entirely  analogous  relation.  The  pectinens  runs 
horizontally,  instead  of  downward  and  outward,  or  even  upward,  and 
is  lengthened  accordingly.  The  pelvicrural  muscles  are  all  shortened 
in  proportion  to  the  displacement  of  the  head, namely, the  rectus  femoris, 
sartorius,  tensor  fasciae  lata1,  biceps,  semimembranosus,  semitendinosus, 
and  gracilis. 

rl "he  older  the  patient,  the  more  pronounced  are  the  deviations  from 
the  normal.     The  capsule  becomes  more  and  more  hour-glass  shaped. 

Fig.  243 


Condition  of  the  capsule  in  congenital  dislocation  of  the  femur. 

Arising  from  the  posterior  acetabular  margin,  it  bridges  over  the  head. 
Lying  close  against  it,  so  that  the  contour  of  the  latter  shows  distinctly 
and  then  turns  forward  and  downward,  becoming  closely  adherent  to 
the  acetabulum  and  forming  a  narrow'  pocket  with  the  shallow  floor 
of  the  cavity,  the  so-called  socket-pocket  of  Lorenz,  from  which  in  turn 
the  ligamentum  teres  runs  to  the  lower  pole  of  the  head.  The  lower 
part  of  the  capsule  therefore  appears  elongated;  it  forms  to  a  certain 
extent  a  pouch  which  merges  beyond  an  isthmus  (the  so-called  "Retre- 


398 


MALFORMATIONS  OF  THE  HIP-JOINT. 


cissement"  of  Bouvier)  into  the  upper  more  spacious  cavity  of  the  cap- 
sule. This  isthmus  is  due  to  a  constriction  made  by  the  tendon  of  the 
iliopsoas  passing  over  the  capsule  at  this  point.  The  accompanying 
diagram  (Fig.  243)  explains  the  form  of  the  capsule  better  than  any 
description.  In  addition  to  the  change  in  form,  the  capsule  is  greatly 
thickened,  especially  the  anterior  lower  portion;  also  the  reinforcing 
ligaments,  particularly  the  Y-ligament. 

The  old  cavity  usually  assumes  a  triangular  form,  being  pointed 
behind  and  above.     (Fig.  244.)     In  all  of  the  author's  operated  cases  the 

cartilage  was  still  present,  al- 
Fig.  244.  though  covered  by  a  fibrous  or 

fatty  deposit.  The  previously 
described  changes  in  the  mus- 
cles increase  naturally  with  the 
age  of  the  patient.  In  addition 
to  the  shortening  resulting;  from 
the  displacement  of  the  head  of 
the  femur  there  is  also  an  atro- 
phic shrinkage  such  as  takes 
place  anywhere  if  the  origin 
and  insertion  of  the  muscles 
are  approximated  permanently. 
At  a  later  period,  in  addition  to 
the  pronounced  atrophy,  there 
is  a  varying  amount  of  fatty  or 
fibrous  degeneration.  Natur- 
ally the  ligaments  and  fascia 
about  the  joint  are  equally  in- 
volved in  the  lengthening  or 
shortening. 

Changes  in  the  pelvis  are 
constant  in  older  patients  as 
the  result  of  the  altered  condi- 
tions of  pressure  and  the  ab- 
normal line  of  traction  of  the 
muscles.  If  the  dislocation  is 
unilateral,  the  affected  side  of 
the  pelvis  is  atrophic  and  the  entire  pelvis  asymmetrical.  As  Guerin 
expresses  it,  the  affected  side  is  twisted  from  before  backward,  from 
below  upward,  and  from  within  outward.  The  flare  of  the  ilium  is 
pushed  inward,  and  is  thus  more  vertical,  whereas  the  ischium  is  rotated 
outward. 

In  bilateral  dislocation  the  pelvis  is  symmetrically  deformed  and 
atrophic.  The  flare  of  both  ilia  is  decreased  —  that  is,  pushed  in- 
ward— and  the  pelvic  inlet  narrowed  in  both  diameters.  The  sacrum 
is  curved  sharply  forward.  The  horizontal  rami  of  the  pubic  bones 
are  elongated,  the  pelvic  arch  is  very  flat,  and  the  tuberosities  of  the 
ischia  rotated  strongly  outward,  thus  increasing  the  transverse  diameter 


Innominate  bone  from  an  adult  with  congenital 
dislocation  of  the  hip. 


CONGENITAL  DISLOCATION  OF  THE  UIP-JOINT. 


399 


of  the  pelvic  outlet  and  shortening  the  anteroposterior  diameter.  De- 
livery, however,  is  not  hindered  by  these  pelvic  anomalies. 

Symptoms. — The  first  symptoms  usually  presented  by  unilateral  con- 
genital dislocation  of  the  hip  are  the  limp  and  the  shortening  of  the 
leg  due  to  the  upward  displacement  of  the  head  of  the  femur  upon  the 
ilium.  (Fig.  243.)  The  shortening  may  he  marked;  2.2.1  to  2.75  inches 
is  not  infrequent.  The  shortening  is  compensated  by  the  patient  in 
walking  by  holding  the  foot  in  a  pronounced  pes  equinus  position. 
Viewed  from  behind,  there  are  flattening  of  the  buttock  on  the  affected 
side  and  lateral  prominence  of  the  trochanter,  the  gluteal  fold  usually 
being  lower  than  on  the  sound  side.  The  head  of  the  femur  is  absent 
at  its  normal  position  and  is  found 

either  directly  beneath  the  anterior-  Fig.  245. 

superior  spine  or  more  frequently 
to  its  outer  side  or  behind  upon  the 
ilium.  The  normal  resistance  of 
the  soft  parts  beneath  the  anterior- 
superior  spine  is  replaced  by  the 
hardness  of  the  head.  The  ringer 
can  be  pushed  deeper  into  the 
tissues  on  the  front  of  the  thigh 
below  the  anterior-superior  spine 
than  normally. 

To  palpate  the  head,  the  child 
is  placed  on  its  back,  the  head  of 
the  femur  seized  between  the 
thumb  and  fingers  of  one  hand, 
the  thigh  grasped  above  the  knee 
with  the  other  and  rotated.  The 
head  can  be  felt  moving  under  the 
fingers  distinctly.  If  the  child  is 
placed  on  its  sound  side  and  the 
thigh  flexed  slightly  and  adducted 
strongly,  the  displaced  head  can 
be  felt  plainly  and  the  greater 
trochanter  recognized  projecting 
prominently  well  above  the  Roser- 
Nelaton  line.  The  child  can  move 
the  limb  freely  in  all  directions.  In 
passive  rotation  a  certain  amount 
of  looseness  of  the  joint  is  usually 
evident.  By  grasping  the  thigh 
above  the  knee  with  one  hand  and 
fixing  the  pelvis  with  the  other,  the 
head  can  be  pushed  up  and  down 

upon  the  ilium  and  the  shortening  of  the  limb  increased  or  diminished 
at  will.  If  crepitus  is  obtained  in  these  movements,  especially  in  rota- 
tion, it  indicates  that  the  ligamentum  teres  is  probably  lacking. 


Unilateral  congenital  dislocation  of  the  hip. 


400 


MALFORMATIONS  OF  TUB  II  IP -JOINT. 


Fig.  246. 


In  walking  the  child  limps,  and  at  each  step  upon  the  affected  limb 
the  head  of  the  femur  pushes  the  soft  parts  backward  and  upward. 
Greater  attention  has  been  paid  to  the  limp  in  recent  years  and  valuable 
conclusions  deduced  for  the  treatment.  Especially  Trendelenburg  called 
attention  to  the  fact  that  the  limping  gait  of  congenital  dislocation  was 
not  due  chiefly,  as  was  formerly  supposed,  to  the  displacement  of  the 
head  of  the  femur  upon  the  pelvis,  but  to  the  changed  direction  of  the 

gluteal  muscles,  especially  the  me- 
dins  and  minimus,  as  it  is  the  glu- 
teals which  hold  the  pelvis  in  a 
horizontal  position  in  walking  or 
standing.  If  a  person  stands  on  one 
leg  and  holds  the  other  up  flexed  at 
the  hip  and  knee,  the  folds  of  the 
buttocks  remain  on  the  same  level. 
If  a  patient  with  congenital  disloca- 
tion of  the  hip  stands  upon  the  af- 
fected limb,  holding  the  other  up  in 
the  same  manner,  the  pelvis  on  the 
sound  side  immediately  sinks,  so  that 
the  gluteal  fold  is  on  a  lower  level 
than  that  of  the  affected  side.  This 
sinking  of  the  pelvis  is  due,  as  shown 
by  Trendelenburg,  to  the  fact  that 
the  abductors,  namely,  the  gluteus 
medius  and  minimus,  are  not  able  to 
hold  the  pelvis  horizontal  on  account 
of  their  changed  line  of  traction. 
Therefore,  in  walking  the  body  sinks 
down  on  the  opposite  side  at  each 
step  upon  the  dislocated  limb. 

Although  the  limping  gait  of  uni- 
lateral dislocation  and  the  waddling 
gait  of  bilateral  dislocation  are  due 
chiefly    to    these    changes    in     the 
glutei,  a  part  of  the  disturbance  is 
certainly  caused   by  the  shifting  of 
the  head  of  the  femur  upon  the  ilium  in  the  act  of  walking.    Delanglade 
has  furnished  irrefutable  evidence  of  this  by  his  studies  of  the  gait  with 
the  Marey  chronophotograph. 

The  pelvis  is  inclined  sharply  forward  in  the  dislocation  and  there 
are  a  marked  lordosis  and  skoliosis  toward  the  affected  side.  The 
skoliosis  is  easily  overcome  by  placing  blocks  under  the  affected  limb, 
and  the  lordosis  disappears  in  the  recumbent  dorsal  position.  The 
thigh  and  hip  are  usually  atrophic;  the  axis  of  the  thigh  runs  from 
without  and  above  downward  and  inward. 

In  bilateral  dislocation  the  local  conditions  are  the  same  on  both 
sides,  but  the  gait  and  the  carriage  are  somewhat  different.     The  gait 


Bilateral  congenital  dislocation  of  the  hip. 


CONGENITAL  DISLOCA  TION  OF  Till:  1111'  JOINT  4(jl 

is  waddling  like  that  of  a  duck,  the  body  falling  to  the  opposite  side  at 
each  step,  so  that  the  deformity  is  recognizable  through  the  clothing. 
The  carriage  of  the  patient  produces  a  striking  lordosis  of  the  lumbar 
vertebrae.  (  Pig.  246. 1  The  short  limbs  usually  support  a  well-developed 
body.  The  pelvis  is  inclined  sharply  forward,  the  body  thrown  back- 
ward; the  prominence  of  the  gluteals  beneath  the  crests  of  the  ilia, 
caused  by  the  displaced  heads,  is  recognized  at  a  glance.  The  thighs 
are  flexed,  slightly  adducted,  and  rotated  inward.  Esmarch  saw  a  case 
in  which  the  adduction  was  so  marked  that  the  thighs  crossed  each 
other  in  walking  or  standing. 

Diagnosis. — In  pronounced  cases  in  older  children  the  diagnosis  is 
very  simple.  In  younger  children,  especially  if  fat,  the  dislocation  may 
be  mistaken  for  other  affections.  It  is  very  frequently  mistaken  for  a 
rhachitic  deformity,  and  it  cannot  be  denied  that  there  is  a  similarity 
between  the  two  affections.  A  child  with  a  pronounced  rhachitic  lordosis 
also  waddles  in  walking,  but  on  examination  the  greater  trochanter  lies 
in  the  Roser-Xelaton  line.  In  congenital  dislocation  the  abnormal 
position  of  the  head  can  be  felt  and  perhaps  shifted,  whereas  in  rickets 
the  head  is  stable  in  its  cavity. 

Typical  coxa  vara  is  very  often  mistaken  for  congenital  dislocation, 
as  the  trochanter  lies  abnormally  high  and  the  limb  is  shortened;  the 
head  is  in  the  cavity,  however,  and  can  be  felt  distinctly.  In  coxa  vara 
abduction  is  greatly  limited  and  the  thigh  is  rotated  strongly  outward, 
btit  the  head  cannot  be  shifted  about.  The  differential  diagnosis  may 
present  difficulties  even  to  the  experienced,  but  the  x-ray  is  an  infallible 
aid  in  clearing  up  the  condition. 

In  paralytic  dislocation  of  the  hip  there  are  also  displacement  of  the 
head  and  trochanter  and  lumbar  lordosis.  Reduction,  however,  can  be 
effected  by  simple  traction  in  the  long  axis  of  the  limb,  whereas  it  is 
impossible  in  congenital  dislocation.  In  the  former  case  the  gluteals 
are  very  markedly  relaxed  and  there  is  evidence  in  the  limb  of  previous 
paralysis,  namely,  paralytic  deformities  elsewhere,  which  will  be  con- 
sidered later. 

Contracture  of  the  hip  is  characterized  by  reflex  muscular  contraction 
during  passive  motion  in  contrast  to  the  absolute  freedom  of  motion  in 
congenital  dislocation.  Spontaneous  separation  of  the  epiphysis  of  the 
upper  end  of  the  femur  following  osteomyelitis  may  give  symptoms 
similar  to  dislocation,  but  in  the  history  the  fact  will  never  be  overlooked 
that  the  child  gave  previous  symptoms  of  fever,  and  that  cicatrices  are 
usually  present  from  perforating  abscesses. 

Prognosis. — The  prognosis  for  recovery  is  usually  unfavorable,  as  any 
cessation  of  the  deformity  is  not  to  be  expected.  Usually  the  condition 
does  not  improve,  but  gets  worse,  as  the  thickened  capsule  or  the  thick- 
ened ligamentum  teres  has  to  support  the  weight  of  the  body  almost 
entirely.  A  genuine  nearthrosis  cannot  be  formed  upon  the  ilium,  as 
the  head  does  not  lie  directly  upon  the  periosteum  or  the  bone,  but  is 
separated  from  it  by  the  capsule  or  the  thickened  flattened  teres  liga- 
ment. The  patients  often  complain  in  the  later  course  of  the  deformity 
Vol.  III.— 26 


402 


MALFORMATIONS  OF  THE  HIP-JOINT. 


of  the  ease  with  which  they  are  fatigued  and  of  the  pains  in  the  joint; 
in  fact,  an  inflammation  may  develop  in  the  latter,  even  tuberculosis. 

Treatment. — In  the  last  few  years  very  great  progress  has  been  made 
in  the  treatment  of  congenital  hip  dislocation.  Previously  the  deformity 
was  generally  regarded  as  incurable  and  the  treatment  was  accordingly 
palliative.  To-day  surgeons  are  in  a  position  to  overcome  the  affection 
in  an  almost  ideal  manner.  The  therapeutic  efforts  which  have  been 
made  against  the  disease  are  easily  divisible  into  three  groups:  First, 
the  efforts  to  hold  the  head  of  the  femur  against  the  ilium  by  means  of 
a  pelvic  brace  or  corset.  Secondly,  continuous  extension  with  weights 
or  apparatus  aiming  to  draw  the  head  down  to  the  level  of  the  cavity 
and  hold  it  there.  These  measures  are  to  be  designated  as  purely  ortho- 
pedic; they  are  of  a  more  or  less  palliative  nature  and  do  not  attempt 
actually  to  cure  the  affection.      Thirdly,  in  contrast  to  these  are  the 

Fig.  247. 


Pelvic  brace  for  unilateral  congenital  dislocation  of  the  hip.     (After  Hoffa.) 

methods  which  are  not  purely  palliative,  but  aim  to  restore  the  head 
directly  to  its  cavity  and  to  hold  it  there,  the  so-called  bloodless  reduc- 
tion methods.  The  open  methods  may  be  either  palliative,  for  example, 
resection,  or  aim  to  produce  a  direct  anatomical  recovery  by  reduction. 
In  glancing  over  the  various  methods  of  treatment  it  will  be  seen  that 
the  goal  of  recovery,  formerly  regarded  as  unattainable  for  congenital 
dislocation  of  the  hip,  has  been  readied  at  the  present  time. 

The  Pelvic  Brace. — The  oldest  treatment  of  dislocation  of  the  hip 
is  with  the  pelvic  brace,  which  is  designed  to  hold  the  head  against 
the  ilium  by  pressure  from  above  and  from  the  sides  upon  the  trochan- 
ters. Dupuytren  was  the  first  to  suggest  the  pelvic  brace,  and  later 
similar  apparatus  were  used  by  Heine,  Bouvier,  Parow,  Kraussold, 
St.  Germain,  Langgaard,  and  many  others.    If  such  a  brace  is  indicated, 


COXa i:\ITAL  DISLOCATION  OF  THE  HIP-JOINT. 


403 


the  author  uses  a  simple  iron  strip  fitted  accurately  to  the  outline  of 
the  pelvis,  so  as  to  obtain  a  good  hold.  A  perineal  strap  is  fastened 
on  the  sound  side;  on  the  affected  side  two  lateral  curved  iron  strips 
run  downward,  to  which  is  attached  a  padded  curved  plate  conformed 
to  the  shape  of  the  great  trochanter  and  fitted  closely  and  accurately 
against  it.     (  Fig.  247.) 

As  it  is  difficult  to  construct  well-fitting  braces,  the  attempt  was  made 
to  fix  the  trochanters  by  using  the  body  as  well  as  the  pelvis  to  support 
the  apparatus,   namely,  by  means 

of    a    corset.       Landerer's    plaster  Fig,  248. 

corset  has  an  extension-piece  which 
presses  upon  the  trochanter.  Nat- 
urally the  corset  can  be  made  of 
other  material.  Recently  cellulose 
and  celluloid  have  been  recom- 
mended. In  general,  it  is  better  to 
make  the  corset  of  cloth  and  insert 
iron  ribs,  as  it  is  much  more  com- 
fortable. The  corset  which  the 
author  uses  is  a  combination  of 
the  one  used  for  skoliosis  and  a 
well-fitting  trochanteric  brace.  ( Fig. 
248.)  Lorenz  has  the  corset  made 
of  celluloid  plates  strengthened 
with  iron  strips,  the  whole  being 
accurately  shaped  over  a  plaster 
model. 

Such  corsets  are  indicated  if  for 
any  reason  reduction  is  not  possi- 
ble, as  they  are  able  at  least  to  im- 
prove the  carriage  of  the  patient 
and  lessen  the  limp  or  waddling. 
An  anatomical  cure  is  not  to  be 
expected.  Further,  a  cure  has  never 
been  obtained  thus  far  by  continu- 
ous extension  with  weights. 

Continuous  weight-extension  was 
warmly  advocated  by  v.  Volkmann 
to  overcome  the  shortening.  By  pro- 
longing the  treatment  for  a  year  he 
attempted  to  change  the  so-called 
mid-position  of  the  joint  by  holding 
the  limb  constantly  abducted.  The 
effect  is  to  lower  the  pelvis  on  the 
affected    side     and    lengthen     the 

shortened  limb.  v.  Volkmann  used  the  extension  only  at  night ;  Buck- 
minster  Brown  applied  it  also  during  the  day.  This  naturally  necessi- 
tated the  recumbent  position  constantly.     In  his  celebrated  case  Buck- 


rset  with  trochanteric  brace.   (After  Hoffa.") 


404 


MALFORMATIONS  OF  THE  HIP-JOINT. 


Fig.  249. 


minster  Brown  kept  the  child  in  bed  for  one  and  a  half  years.  The 
so-called  "complete  recovery"  did  not  last,  however,  but  was  followed 
by  recurrence.  The  American  colleagues  who  tried  the  method  later, 
particularly  the  conscientious  Bradford,  were  not  successful.  It  is  cer- 
tainly not  worth  trying,  for  it  is  a  positive  torture  for  the  patient  to  lie 
in  bed  for  a  year. 

Portable  Apparatus. — In  order  not  to  keep  the  patient  in  bed,  but 
still  be  able  to  apply  extension,  many  such  apparatus  have  been  recom- 
mended, as,  for  example,  recently  by  Dolega.  Hessing's  sheath  ap- 
paratus has  become  celebrated  since 
Hessing  stated  that  he  had  obtained  a 
cure  with  it.  The  author  has  had 
opportunity  to  examine  a  large  num- 
ber of  Hessing's  former  patients,  and 
must  admit  that  he  succeeded  in  a  few 
cases  of  unilateral  dislocations  in  hold- 
ing the  head  in  its  original  position, 
namely,  below  and  to  the  outer  side 
of  the  anterior  superior  spine,  and 
preventing  the  aggravation  of  the  de- 
formity which  usually  takes  place  with 
years.  In  other  cases  he  had  not  been 
successful  and  the  head  lay  behind 
upon  the  ilium.  The  apparatus  was 
entirely  unsuccessful  in  bilateral  dislo- 
cation. The  heads  of  the  femurs  lay 
posteriorly  upon  the  ilium,  and  the 
patients  waddled  cumbrously  about  in 
their  apparatus.  If  the  apparatus  was 
removed  merely  for  a  few  days,  dislo- 
cation was  evident,  and  in  addition 
the  muscles  were  entirely  disabled  by 
disuse. 

Schede  attempted  to  lengthen  the 
limb  in  unilateral  dislocation  by  hold- 
ing it  continually  abducted   in  a  sup- 

Schede's  abduction  apparatus  for  unilateral     porting    apparatus.       Scliede's    Splint    IS 

congenital  dislocation  of  the  hip.         based    upon    the    experience    that    in 

almost  every  case  of  congenital  dis- 
location of  the  hip  the  head  of  the  femur  can  be  held  immovably  against 
the  ilium  by  slight  lateral  pressure  upon  the  great  trochanter  if  the 
limb  is  found  to  be  abducted  and  secondary  changes  have  not  taken 
place  in  the  head  or  upper  posterior  margin  of  the  cavity  by  their  rubbing 
together  in  using  the  limb.  The  splint  is  therefore  constructed  so  as 
to  abduct  the  thigh  and  exert  lateral  pressure  upon  the  greater  tro- 
chanter.    (Fig.  249.) 

In  contrast  to  the  above  methods,  which  sought  to  obtain  only  a 
partial  result,  should  be  mentioned  a  number  of  others  which  aimed 


CONGENITAL  DISLOCATION  OF  THE  HIP-JOINT.  405 

at  complete  cure.  Lannelongue,  by  his  me*thode  sclerogene  hoped  to 
stimulate  a  growth  of  fibrous  tissue  to  support  the  head  by  repeatedly 
injecting  a  10  per  cent,  zinc  chloride  solution  about  the  head  after 
drawing  down  the  extremity  as  much  as  possible.  In  the  author's 
experience  the  method  gives  no  permanent  results. 

Bloodless  Reduction. — The  bloodless  reduction  method  gives 
positive  results.    The  French  orthopaedists  were  the  first  to  attempt  the 

actual  restoration  of  the  head  to  its  cavity.  (Lafond  and  Duval,  Humbert 
and  Jacquier,  and  especially  Pravaz  in  Lyon.)  Pravaz'  experiments 
are  unfortunately  consigned  to  oblivion,  and  it  is  not  until  1<SS7  that 
Paci  announces  that  he  has  developed  a  method  that  is  supposed  to  be 
very  serviceable.  Paci  does  not  attempt  actual  reduction,  but  merely 
fixes  the  head  as  low  as  possible,  so  that  it  may  form  a  new  joint  near 
the  old  cavity. 

Pad's  Method. — Paci  draws  the  head  down  in  the  following  manner: 
With  the  patient  in  a  horizontal  position  upon  a  flat,  firm  surface  the 
pelvis  is  held  firmly,  the  thigh  flexed  maximally  on  the  pelvis,  and  the 
leg  on  the  thigh.  The  head  thus  descends  upon  the  ilium  and  may  be 
forced  further  by  pressing  against  the  knee.  The  maximally  flexed 
thigh  is  now  abducted  so  that  the  head  glides  toward  the  old  cavity, 
and  while  still  held  flexed  and  abducted  it  is  rotated  outward  until  the 
axis  of  the  leg  is  at  right  angles  to  the  body  to  force  the  head  as  far 
as  possible  into  the  old  cavity;  the  thigh  is  then  extended  slowly  on  the 
pelvis  and  the  leg  on  the  thigh.  The  proper  position  of  the  head  is 
then  maintained  for  a  month  by  a  splint.  Continuous  extension  by  v. 
Volkmann's  method  is  then  applied  for  three  months,  and  at  the  end 
of  the  fourth  month  the  patient  is  allowed  to  walk  wearing  a  supporting 
apparatus. 

Paci  employed  this  method  almost  exclusively  on  old  patients,  but 
nevertheless  obtained  very  remarkable  results.  Favorable  reports  have 
been  made  of  the  method  by  other  authors.  (Redard,  Regnoli,  Nota, 
Cesi,  Rota,  and  Motta.)  With  it  the  author  has  often  obtained  good 
reduction  in  young  children.  Its  value  is  accordingly  established.  It 
is  further  upheld  by  an  anatomical  specimen  from  a  seven-year-old  girl 
who  died  of  dysentery  four  months  after  Paci  had  effected  reduction. 
The  heads  stood  firm  close  to  their  old  cavities;  the  ligamentum  teres 
was  lacking  on  both  sides.  The  credit  is  due  to  Paci,  therefore,  to  the 
author's  mind,  of  being  the  first  to  have  actually  reduced  the  head  into 
the  region  of  the  old  cavity,  and  to  have  presented  evidence  of  it, 
although  Paci  admits  that  usually  he  did  not  effect  a  reduction,  but 
merely  a  transposition  of  the  head. 

Schede  was  the  first  one  in  Germany  to  recommend  the  bloodless 
reduction  methods  warmly.  He  sought  to  bring  the  head  into  the 
region  of  the  cavity  by  overcoming  the  resistance  of  the  shrunken  soft 
parts  by  repeated  forcible  traction.  He  used  an  extension  apparatus 
constructed  by  Eschbaum,  which  the  author  would  recommend,  how- 
ever, after  many  trials,  only  for  the  most  urgent  conditions.  (Fig.  250.) 
To  obviate  the  danger  of  reluxation,  which   in  the  greater  majority 


40G 


MALFORMATIONS  OF  THE  HIP- JOINT. 


of  cases  results  from  outward  rotation  of  the  upper  end  of  the  femur 
on  its  long  axis,  Schede  has  recently  performed  osteotomy  after  reducing. 
Schede's  Osteotomy. — For  cases  of  pronounced  sagittal  position  of 
the  head  the  method  is  as  follows:  After  the  head  has  been  rotated 
inward  into  the  cavity  the  limb  is  rotated  and  abducted  cautiously,  and 
the  position  determined  by  which  the  head  is  best  retained  in  the  cavity. 
A  position  of  greater  or  less  inward  rotation  appears  in  every  case  to 
be  the  best,  and  under  all  circumstances  should  be  such  that  the  head 
previously  felt  beneath  the  skin  is  turned  toward  the  axis  of  the  femur 
and  is  not  any  more  prominent  in  front  than  the  normal  head.  To  be 
sure,  it  would  be  almost  impossible  to  restore  the  normal  relations 
entirely  in  this  respect,  as  even  under  favorable  circumstances  the  head 
will  not  enter  deeply  enough  into  the  cavity.  A  circular  plaster  splint 
is  now  very  carefully  applied  encircling  the  pelvis  and  reaching  to  the 

Fig.  250. 


Schcde's  extension  table  for  bloodless  reduction  of  congenita]  dislocation  of  the  hip. 


toes  in  all  cases  in  which  the  tension  of  the  outward  rotators  resists 
inward  rotation  noticeably.  If  the  limb  remains  rotated  inward  of 
itself,  the  plaster  splint  may  end  at  the  calf.  The  padding  at  the  knee 
should  always  be  thin  and  the  plaster  moulded  accurately  to  the  con- 
dyles, as  they  furnish  the  hold  necessary  to  maintain  inward  rotation. 
The  thigh  remains  in  this  position  from  one  and  one-half  to  three  months, 
according  to  the  resistance  of  the  outward  rotators. 

Schede  lays  the  child  upon  his  extension  table,  upon  which  the 
operation,  correction,  and  application  of  the  dressing  and  plaster  splint 
are  to  be  completed  without  the  slightest  change  in  the  position  of  the 
patient.  The  traction  anklets  are  put  on  and  the  cranks  turned  until 
traction  of  about  20  pounds  is  exerted  on  each  limb,  the  inward  rotation 
and  abduction  existing  previously  in  the  plaster  splint  being  carefully 
maintained.     The  perineum  rests  against  the  counterextension  brace, 


COXi.EMTAL  dislocation;  OF  THE  HIP  JOINT.  407 

the  pelvis  and  both  extremities  being  freely  accessible.  Schede  now 
takes  a  gold-plated  iron  nail  of  appropriate  length  and  drives  it  directly 
through  the  skin  into  the  trochanter  and  neck  of  the  femur,  being  careful 
to  strike  the  axis  of  the  hitter.  It  is  driven  in  till  the  point  lies  aboul 
in  the  middle  of  the  head.  It  should  lie  horizontally  or  slant  slightly 
upward  and  inward.  It  projects  outward  about  1.25  inch  beyond  the 
skin,  and  forms  a  good  handle  with  which  to  rotate  the  upper  fragment 
into  any  desired  position  after  osteotomy.  A  stout  silk  cord  is  tied  to 
the  nail  at  the  head  and  held  by  an  assistant  or  tied  to  the  counter- 
extension  brace,  to  hold  the  upper  end  of  the  femur  in  the  desired 
position. 

At  first  Schede  divided  the  bone  close  beneath  the  lesser  trochanter, 
but  this  is  not  proper,  as  the  operator  is  not  dealing  with  an  ankylosis, 
the  usual  indication  for  subtrochanteric  osteotomy,  but  rather  with  an 
abnormally  movable  joint.  In  spite  of  the  hold  upon  the  head  given 
by  the  nail,  it  is  not  always  possible  in  such  high  osteotomy  to  avoid 
slight  displacement,  namely,  flexion  and  abduction  of  the  upper  frag- 
ment. Therefore  Schede  very  soon  made  the  division — naturally  linear 
subcutaneous  osteotomy — at  the  lower  third  of  the  femur.  An  adjustable 
support  and  sand-bag  are  placed  under  the  thigh  at  the  point  at  which 
the  bone  is  to  be  divided  with  the  chisel.  After  dividing  the  bone  the 
lower  fragment  is  rotated  outward  till  the  patella  faces  forward;  the 
wound  is  then  sutured,  and  a  small  dressing  of  airol  gauze  is  placed 
over  it  and  about  the  nail  and  fastened  with  Lima's  zinc  plaster,  and  a 
plaster  splint  applied.  As  padding  for  the  pelvis  he  uses  soft  felt,  for 
the  limb  wool  roll-bandages  (stockinet).  If  the  plaster  splint  is  wrell 
moulded  to  the  condyles  of  the  femur,  rotation  is  impossible  even  if 
the  foot  is  left  free. 

At  first  Schede  simply  included  the  nail  in  the  plaster  splint,  but  on 
one  occasion  found  in  one  or  two  weeks  that  the  child  complained  of 
pain  and  discovered  that  the  thinness  of  the  body  allowed  movements 
within  the  splint  which  could  not  be  followed  by  the  nail;  since  then 
he  has  surrounded  the  nail  with  cotton  before  applying  the  splint.  The 
inward  rotation  is  maintained  equally  well  and  the  nail  can  follow  the 
movements  of  the  body.  In  general  neither  the  nail  nor  the  osteotomy 
gives  any  trouble.  Some  of  the  children  have  painful  muscular  twitching 
for  a  few  days,  as  is  common  in  fractures,  but  it  soon  ceases.  The  nail 
should  be  withdrawn  in  five  weeks.  In  six  weeks  the  consolidation  is 
such  that  a  short  portable  splint  can  be  worn. 

The  above  is  Schede's  method  as  he  employs  it  at  the  present  time, 
but  it  should  be  added  that  he  reduces  by  Lorenz'  method  in  appro- 
priate cases. 

Lorenz'  Method. — Lorenz  unquestionably  deserves  great  credit  for 
having  shown  that  it  is  possible  in  the  greater  majority  of  cases,  at  least 
in  very  young  patients,  to  actually  restore  the  head  to  its  old  cavity  by 
a  bloodless  method.  By  the  Lorenz  method  the  head  of  the  femur, 
dislocated  upward,  is  brought  down  to  the  level  of  the  cavity;  this  rudi- 
mentary cavity  is  enlarged  and  the  head  of  the  femur  implanted,  so 


408  MALFORMATIONS  OF  THE  HIP-JOINT. 

that  finally  under  the  influence  of  the  body-weight  the  artificially  prepared 
joint  is  made  stable,  movable,  and  useful. 

The  teclmic  of  the  operation  is  as  follows :  The  patient  is  anaesthetized, 
cotton  anklets  are  placed  around  the  ankles,  and  with  a  thumb-screw 
slowly  increasing  traction  is  made  upon  the  limb,  countertraction  being 
by  means  of  a  perineal  cloth  fastened  to  the  upper  end  of  the  table.  Trac- 
tion is  continued  until  the  greater  trochanter  lies  in  the  Roser-Nelaton 
line.  During  the  descent  of  the  trochanter  the  adductor  tendons  are 
stretched  tightly;  they  stand  out  like  tense  cords.  It  is  now  essential  to 
overcome  this  tension  of  the  tendons.  This  is  done  by  massaging  and 
kneading  the  tense  parts  and  pressing  the  tendons  in  with  both  thumbs. 
One  can  feel  the  tendons  yielding  under  the  thumbs  as  they  are  torn  by 
the  pressure.  If  they  do  not  give,  they  may  be  divided  subcutaneously 
without  damage. 

The  head  having  been  brought  down  to  the  level  of  the  cavity  in 
order  to  implant  it,  it  is  necessary  that  the  approach  to  the  cavity  should 
be  opened  as  wide  as  possible  and  the  head  directed  toward  it.  This 
is  done  by  removing  the  extension  and  flexing  the  thigh  strongly  and 
rotating  inward  slightly.  If  the  thigh  is  now  abducted  to  an  angle  of 
90  degrees  the  head  of  the  femur  slips  over  the  posterior  margin  and 
into  the  acetabulum,  often  with  a  loud  snap  appreciable  at  some  distance, 
and  with  a  jerk  that  can  be  plainly  felt  by  the  operator.  This  jerk  is 
a  positive  sign  that  the  reduction  is  successful.  The  head  may  be 
levered  more  easily  over  the  rim  of  the  acetabulum  by  using  a  wooden 
wedge  as  a  fulcrum  under  the  trochanter. 

It  is  now  necessary  to  dilate  the  cavity  as  much  as  possible  by  the 
direct  pressure  of  the  head.  To  do  this,  the  thigh  is  abducted  to  the 
maximum  and  hyperextended  so  that  the  head  appears  in  the  soft  parts 
of  the  groin.  By  direct  pressure  upon  the  head  it  is  bored  as  deeply  as 
possible  into  the  cavity.  If  the  thigh  is  then  left  hanging  abducted,  the 
reduction  usually  persists.  With  the  slightest  decrease  in  abduction  the 
head  slides  out  again  and  becomes  reluxated,  usually  with  an  appre- 
ciable jerk. 

In  every  case  it  must  be  ascertained  by  what  degree  of  abduction  the 
reduction  is  best  maintained,  and  in  this  position  the  hyperextended 
thigh  is  immobilized  in  a  closely  moulded  plaster  splint  reaching  to  the 
knee.  In  order  to  make  the  child  ambulant,  the  sound  foot  is  elevated 
by  a  correspondingly  high  cork,  wood,  or  felt  sole.  In  spite  of  the 
strong  abduction  of  the  thigh  the  children  usually  learn  to  walk  very 
easily.  The  use  of  the  limb  is  supposed,  and  is  intended  by  Lorenz, 
to  drive  the  head,  so  to  speak,  into  the  cavity  and  so  form  a  new  stable 
joint. 

The  first  splint  remains  from  ten  to  twelve  weeks;  each  time  the 
splint  is  renewed  the  abduction  is  gradually  diminished  until  the  stability 
of  the  joint  is  evident.  Lorenz  immobilizes  altogether  for  six  months. 
The  muscles  of  the  thigh,  especially  the  gluteals,  are  strengthened  as 
much  as  possible  by  appropriate  massage  and  exercise,  for,  as  Lorenz 
expresses  it,  strong  gluteals  are  the  most  reliable  guards  against  recur- 


CONGENITAL  DISLOCATION  OF  THE  HIP  JOINT. 


•JO!) 


rence.    In  order  to  maintain  the  abduction  the  children  wear  a  heel  ().."> 
to  1  inch  higher  for  some  time  on  the  other  foot. 

In  bilateral  dislocation  Lorenz  advises  to  reduce  one  joint  and  then 
the  other  after  the  first  lias  become  stable,  cither  by  the  bloodless 
method  or  by  open  operation.  The  author  has  found  that  one  can  do 
both  sides  very  well  at  one  sitting.  The  splint  must  then  be  applied 
with  both  thighs  abducted  to  a  right  angle  and  hyperextended.  ( Fig. 
251.)  This  first  splint  is  changed  after  the  second  or  third  week  and 
the  thighs  adducted  so  that  the  patients  can  go  about  to  sonic  extent 
at  least  unaided. 

Fig.  251. 


\ 

pj*r 

rr 

p*^ 

^£     "i-^K*" 

91          f     X 

The  bandage  applied  after  the  reduction  of  bilateral  dislocation,  showing  a  favorite  method  of 
progression  on  a  chair.     (Whitman.) 


Recently  Lorenz'  method  has  been  modified  by  Kiimmell,  who  usually 
omits  the  preliminary  extension  and  begins  by  abducting  the  thigh.  A 
further  modification  which  the  author  would  like  to  recommend  is  that 
the  thigh,  after  being  abducted  to  a  right  angle  and  rotated  outward 
forcibly,  should  be  carried  back  and  forward  toward  the  body  from  the 
horizontal  like  a  pump-handle  with  gradually  increasing  hyperextension. 
The  cavity  is  thus  widened  very  satisfactorily  and  the  tense  anterior 
wall  of  the  capsule  stretched  thoroughly.  For  example,  the  author  was 
able  to  reduce  a   dislocation   in  an   older  child  in  whom  Lorenz  had 


410  MALFORMATIONS  OF  THE  HIP-JOINT. 

attempted  reduction  unsuccessfully.  Further,  the  author  does  not 
immobilize  the  limbs  in  strong  abduction  and  outward  rotation,  but  in 
slight  abduction  and  inward  rotation.  Much  time  is  thus  saved  and 
the  results  arc  better  with  reference  to  permanent  reduction. 

Lorenz'  method  was  the  first  to  make  bloodless  reduction  popular, 
and  the  question  is  now  as  to  its  final  results.  The  experience  gained 
from  many  hundreds  of  cases  has  shown  that  in  the  great  majority  of 
them  reduction  takes  place  with  a  jerk  that  can  be  heard  or  felt.  There 
are  a  few  cases — Lorenz  and  the  author  have  reported  such — in  which 
reduction  was  impossible,  even  in  very  young  children. 

The  retention  of  the  head  in  its  cavity  is  a  different  matter.  Here  most 
of  the  cases  are  in  the  minority  in  which  the  head  actually  remained  per- 
manently in  the  cavity,  and  which  were  verified  by  the  a*-ray  and  the 
anatomical  specimen.  In  the  great  majority  of  instances  the  head  slips 
out  forward  and  upward  over  the  cavity  in  time  and  forms  for  itself  a 
stable  secondary  position  beneath  and  close  to  the  anterior  inferior 
spine.  The  neck  of  the  femur  then  usually  lies  entirely  in  the  sagittal 
plane  and  can  be  felt  throughout  its  full  extent.  The  thigh  often  assumes 
a  position  of  pronounced  outward  rotation  and  abduction.  Usually  the 
head  is  freely  movable;  the  cases  in  which  reduction  actually  persists 
are  characterized  by  stiffness  in  the  joint  lasting  for  some  time.  The 
marked  abduction  does  not  require  any  special  treatment.  It  usually 
disappears  finally.  Even  the  annoying  outward  rotation  of  the  thigh 
at  the  outset  lessens  with  time,  so  that  secondary  operation  to  improve 
the  position  of  the  thigh  is  rare. 

The  result  of  the  Lorenz  bloodless  method  is  therefore  an  actual 
reduction  in  rare  cases,  a  transposition  of  the  head  in  the  majority  of 
the  cases,  so  that  the  head  retains  the  same  position  permanently  as 
obtained  by  the  methods  of  Paci  and  Schede.  This  result  cannot  cause 
surprise.  Evervone  who  knows  the  pathological  anatomy  of  hip  dislo- 
cation must  admit  from  the  first  that  the  head  cannot  secure  any  firm 
hold  in  the  cavity,  even  if  brought  against  it.  The  deformed  head 
cannot  fit  into  the  triangular  cavity,  and  as  the  latter  represents  an 
inclined  plane  the  head  has  to  slide  upward  over  it  even  if  both  bones 
are  in  accurate  apposition.  Frequently  this  is  not  the  case,  however, 
especially  if  the  ligamentum  teres  is  present,  for  the  ligament  then 
necessarily  becomes  interposed  between  the  head  and  the  cavity  and 
prevents  permanent  contact  of  the  two  bones.  The  author  therefore 
believes  that  the  method  recently  proposed  by  Witzel  to  prevent  the 
ascent  of  the  head  by  driving  in  nails  above  it  will  not  meet  with  very 
much  success. 

Lorenz'  method  is  a  great  advance,  however,  for  the  functional  results 
are  generally  very  satisfactory.  Children  with  unilateral  dislocation 
often  walk  so  well  that  the  previous  deformity  is  hardly  noticeable,  and 
those  with  bilateral  dislocation  lose  the  lordosis  and  walk  with  only 
slight  swaying  of  the  body.  The  method  is  limited,  however,  by  the 
age  of  the  patient.  Beyond  the  sixth  year  it  is  very  seldom  successful, 
and  Lorenz  does  not  advise  its  use  after  the  tenth  year.     The  dangers 


CONGENITAL  DISLOCATION  OF  THE  HIP-JOINT. 


Ill 


of  bloodless  reduction  in  younger  children,  according  to  Lorenz,  are 
slight.  In  older  patients  they  consist  in  laceration  <>f  the  soft  parts, 
suppuration  of  the  1  >l<  »< >< !  extravasate,  suppuration  of  the  hip-joint, 
paralysis  of  the  sciatic,  fracture  of  the  femur     in  fact,  the  author  has 

had  a  case  with  convulsions,  symptoms  similar  to  shock,  and  death. 
These  drawbacks  warn  the  surgeon  not  to  force  the  reduction  or  to 
attempt  it  in  children  too  old. 

Mikulicz'  Method.  As  the  last  of  the  bloodless  methods,  but  by  no 
means  the  worst,  should  be  mentioned  that  of  Mikulicz  for  very  young 
children.  Mikulicz  has  contrived  a  very  ingenious  apparatus  in  which 
he  places  the  child  for  several  hours  daily  with  the  limbs  extended, 
abducted,  and  rotated  outward,  thus  bringing  the  head  gradually  down 
opposite  the  acetabulum.  I  )uring  the  rest  of  the  day  the  child  is  allowed 
to  go  about.     Great  stress  is  also  laid  upon  the  strengthening  of  the 

Fro.  252. 


The  Mikulicz-Hoffa  type  of  apparatus  for  1  lie  reduction  of  congenital  dislocation  of  the  hip  in 

young  children 

muscles.  The  author  has  used  Mikulicz'  apparatus  many  times  and 
found  it  very  practical.  The  only  disadvantage  is  the  length  of  time 
required;  the  author  has  never  obtained  a  positive  result  before 
one  to  one  and  a  half  years.  This  disadvantage  can  he  overcome  by 
combining  the  method  with  that  of  Lorenz.  For  children  up  to  two 
years  the  author  first  uses  the  Lorenz  method  under  ana\sth(  sia,  and  so 
brings  the  head  and  cavity  into  contact  at  once.  After  two  or  three 
weeks  the  plaster  splint  is  removed  and  the  child  laid  in  Mikulicz' 
apparatus.  As  the  head  is  now  opposite  the  cavity  it  is  better  not  to 
rotate  the  limb  outward  in  the  apparatus,  but  inward  on  account  of 
the  usual  anteversion  of  the  head.  The  author  has  therefore  modified 
the  Mikulicz  apparatus  SO  that  the  limb  can  be  rotated  inward  or  outward 
in  it.  Fig.  252  shows  the  modified  apparatus,  in  which  the  children 
lie  several  hours  during  the  day,  or  even  at  night,  with  the  limbs  extended, 


412  MALFORMATIONS  OF  THE  HIP- JOINT. 

abducted,  and  rotated  inward.  They  become  accustomed  to  it  so 
rapidly  that  they  sleep  the  entire  night  in  it.  Every  day  the  thigh  mus- 
cles, especially  the  hip  muscles,  are  massaged  and  strengthened  by  exer- 
cises. When  moving  about  the  children  wear  the  jacket  shown  in  Fig. 
248.  By  this  method  the  author  has  obtained  excellent  results  and  in 
a  few  cases  absolute  recovery,  as  shown  by  the  local  condition,  the  gait, 
and  the  a;-ray.  In  other  instances  reduction  was  not  complete,  but 
merely  a  transposition  of  the  head,  as  obtained  by  the  methods  of  Paci, 
Lorenz,  and  Schede,  yet  with  a  very  good  functional  result. 

So  at  the  present  time,  in  the  bloodless  methods  of  Paci,  Schede, 
Lorenz,  and  Mikulicz,  we  have  the  possibility  of  reducing  con- 
genital dislocation  of  the  hip  in  a  manner  formerly  regarded  as  impos- 
sible. Naturally,  in  view  of  the  existing  defects  of  the  bones,  the 
children  cannot  be  made  absolutely  normal,  but  satisfactory  functional 
results  can  be  obtained.  Which  method  to  apply  in  the  individual  case 
will  be  determined  by  the  individuality  of  the  operator  and  the  patient. 
Generally  the  author  uses  Mikulicz'  method  for  children  up  to  the 
second  year,  as  it  is  the  most  comfortable  and  most  rapid.  For  older 
children  he  uses  either  the  method  of  Schede  or  Lorenz,  according  to 
the  case,  and  follows  out  the  after-treatment  as  given  by  these  authors. 

There  are  therefore  many  roads  to  success  as  far  as  allowed  by  the 
anatomical  peculiarity  of  the  joint  affected.  If  the  difficulties,  however, 
are  insurmountable,  and  reduction  is  impossible  or  followed  by  reluxa- 
tion,  the  open  operation  is  still  useful  and  often  produces  an  almost 
ideal  result  in  these  severe  cases. 

Guerin  was  the  first  to  describe  the  open  operation.  He  proceeded 
on  the  theory  of  primary  muscular  retraction,  and  accordingly  did  a 
tenotomy  of  all  muscles  about  the  great  trochanter.  At  the  same  time 
he  turned  his  attention  to  the  maldevelopment  of  the  cavity  and  scarified 
the  head  subcutaneously  in  order  to  make  it  adhere  to  the  ilium.  The 
results,  however,  were  not  permanent.  His  tenotomy  was  repeated  by 
Bouvier,  the  younger  Pravaz,  Corridge,  and  especially  by  Brodhurst, 
who  is  supposed  to  have  been  successful  with  this  operation. 

As  a  curiosity  should  be  mentioned  the  operation  of  the  celebrated 
osteotomist  Mayer,  of  Wiirzburg,  namely,  osteotomy  of  the  other  femur 
to  make  it  the  same  length  as  the  affected  limb. 

Hitter  constructed  a  rational  plan  of  operation:  After  exposing  and 
removing  the  atrophic  head  he  intended  to  unite  periosteal  flaps  freed 
from  the  femur  and  ilium,  but  did  not  ever  perform  it.  De  Paoli  and 
Israel  nailed  and  sutured  the  head  of  the  femur  to  the  ilium  without 
success.  Konig,  utilizing  the  knowledge  acquired  in  transplantation 
of  bone-periosteal  flaps  in  plastic  operations  on  the  nose,  conceived  of 
forming  a  new  cavity  or  a  bony  barrier  to  prevent  the  outward  displace- 
ment of  the  head  by  chiselling  off  a  flap  from  the  ilium,  turning  it  down 
and  suturing  it  to  the  capsule,  at  the  same  time  making  traction  on  the 
limb  to  draw  down  the  head  of  the  femur  as  far  as  possible,  and,  further, 
to  hold  it  there  after  the  operation.  The  operation  was  performed  by 
Konig,  Gussenbauer,  and  Schonborn,  and  produced  some  improvement, 


CONGENITAL  DISLOCATION  OF  THE  HIP-JOINT. 


413 


but  was  later  abandoned  by  Konig  after  he  had  convinced  himself  that 

the  author's  operation  gave  better  results.  Resection  of  the  head  of  the 
femur,  first  employed  by  Hose  and  Rever  for  congenital  dislocation,  was 
popularized  by  Margary.  Its  results  left  much  to  be  desired,  and  the 
operation  is  seldom  used  at  the  present  time.  The  author  would  only 
employ  it  if  symptoms  of  coxitis  developed  in  the  dislocated  joint,  as 
occasionally  happens  later  in  life. 

Hoffa-Lorenz  Operation. — The  only  operation  to  be  considered  at 
the  present  time  is  the  open  reduction  of  the  dislocated  head  into  the 
enlarged  old  cavity.  The  following  description  is  of  the  operation  as 
the  author  performs  it  at  present  with  the  best  results: 

The  patient,  being  prepared  and  anaesthetized,  is  placed  in  the 
semilateral  position.  An  aseptic  countertraction  pad  is  placed  against 
the  perineum  and  traction  made  upon  the  limb  by  an  assistant.  In 
older  patients  extension  is  made  with  the  Lorenz  screw  and  cotton 
anklets.  The  head  being  drawn  down  and  held  at  the  level  of  the 
cavity,  a  2.5-inch  incision  is  made  downward,  beginning  0.25  inch  from 
the  upper  anterior  border  of  the  great  trochanter.     (Fig.  253.)     The 

Fig.  253. 


Incisions  of  Lorenz  and  Hoffa  for  open  reduction. 


fascia  lata  is  incised  and  in  older  children  nicked  transversely.  The 
gluteus  medius  and  minimus  beneath  are  retracted  upward  and  the 
capsule  of  the  hip-joint  exposed  in  its  entire  extent.  The  capsule  is 
incised  transversely,  the  extended  limb  being  meanwhile  rotated  out- 
ward. If  the  ligamentum  teres  is  present,  it  holds  the  head;  it  is  first 
divided  with  the  scissors  close  to  the  head,  seized  with  a  toothed  forceps, 
pulled  out,  and  divided  at  its  attachment  on  the  lower  margin  of  the 
cavity.  The  head  is  thus  fully  exposed,  and  may  be  pushed  aside  and 
the  entire  cavity  examined  with  the  finger  and  excavated. 

The  third  part  of  the  operation  is  the  formation  of  the  new  cavity. 
The  author  uses  various  sized  spoons  with  bayonet-shaped  handles. 
Doyen's  joint-drill  is  very  useful.  The  new  cavity  should  be  deep  and 
broad,  and  the  walls  should  be  fairly  sheer,  especially  above,  to  give 
good  support  to  the  head. 

The  last  and  most  important  step  in  the  operation  is  the  reduction 
of  the  head.  In  young  children  this  is  usually  extremely  easy;  in  older 
patients  it  is  often  very  difficult.    The  hindrance  lies  to  a  great  extent 


414  MALFORMATIONS  OF  THE  HIP-JOIST. 

in  the  soft  parts;  exceptionally  it  is  the  form  of  the  head.  The  shortening 
of  the  soft  parts  is  overcome  by  forced  traction  and  thorough  division 
of  the  anterior  part  of  the  capsule.  Occasionally  it  will  be  necessary 
to  nick  the  adductors  with  a  tenotome  or  to  divide  the  tendons  in  the 
popliteal  space.  If  the  hindrance  is  in  the  form  of  the  head,  it  must 
be  modelled  to  fit  the  cavity. 

The  reduction  itself  will  vary  in  individual  cases,  and  must  be  experi- 
mented with.  It  may  be  effected  by  simple  traction  (especially  in  chil- 
dren), the  head  sliding  in  with  an  audible  jerk;  or  it  may  be  necessary 
to  abduct  strongly  and  rotate  inward.  Sometimes  it  is  best  to  flex  the 
limb  at  the  hip  and  knee,  then  extend  forcibly  and  rotate  inward  or 
outward  with  pressure  upon  the  trochanter.  If  properly  reduced,  it 
should  not  be  possible  to  force  the  head  from  the  cavity  by  strong 
adduction  or  outward  rotation.  The  author  then  packs  the  wound  with 
sterile  gauze,  applies  an  aseptic  gauze  dressing  and  a  plaster  splint,  the 
limb  being  held  abducted  and  rotated  inward  by  the  assistant,  while 
also  maintaining  extension  and  counterextension.  The  child  is  then 
placed  in  a  Phelps  bed. 

The  first  dressing  remains  from  four  to  eight  days.  The  author  then 
removes  the  tampon  and  simply  draws  the  wound  together  with  a  gauze 
roll.  This  is  changed  again  at  the  end  of  eight  days.  The  wound  has 
generally  healed  in  fourteen  days  after  the  first  change  of  dressing,  or  at 
the  most  there  are  a  few  superficial  granulating  spots  to  be  touched  with 
silver  nitrate  or  covered  with  adhesive  strips.  To  prevent  contractures 
and  to  mobilize  the  muscles  of  the  entire  limb,  especially  the  hip  muscles, 
energetic  massage  and  electricity  are  applied  daily  with  exercises, 
particularly  abduction  movements.  If  aseptic,  the  operation  is  without 
danger.  In  the  author's  last  100  cases,  in  which  the  muscles  were 
protected  carefully,  he  has  not  lost  a  patient. 

In  regard  to  the  results  of  the  operation,  it  is  impossible  to  restore* 
absolutely  normal  relations  even  by  the  most  successful  bloodless  or  open 
operation.  What  may  be  expected  in  unilateral  dislocation  is  to 
overcome  the  shortening  of  the  limb,  to  give  the  femur  a  firm  support 
on  the  pelvis,  and  to  restore  the  normal  line  of  traction  of  the  gluteals. 
Considering  that  the  aim  of  treatment  is  essentially  restoration  of  func- 
tion, the  final  results  obtained  by  strengthening  the  muscles  by  massage 
and  exercises  may  be  designated  as  faultless  in  this  respect.  By  inclin- 
ing the  pelvis,  the  children  compensate  the  slight  shortening  left,  and 
finally  walk  so  well  that  the  unprejudiced  observer  will  often  have  diffi- 
culty to  determine  which  is  the  sound  and  which  the  operated  limb. 
In  bilateral  dislocation  the  operation  removes  the  deforming  lordosis, 
diminishes  the  waddling  gait  to  a  minimum,  restores  the  proper  attitude 
of  the  limb,  and  improves  the  abduction. 

The  earlier  the  children  are  operated  upon,  the  better  the  final  result. 
The  best  time  for  the  operation,  to  the  author's  mind,  is  from  the  third 
to  the  eighth  year.  In  general  the  tenth  year  is  the  limit  of  operability. 
Naturally  it  is  not  impossible  that  the  operation  may  be  successful  at 
a  later  period,  but  the  deformity,  increasing  with  age,  makes  it  impossible 


CONGENITAL  DISLOCATION  OF  THE  HIP  JOINT.  415 

to  guarantee  a  complete  result.  Furthermore,  the  difficulty  of  reduction 
increases,  and  with  it  the  possibility  of  infection.  To  repeat,  therefore, 
the  author  would  recommend  that  the  operation  should  be  limited  to 
the  tenth  year. 

What  shall  he  done  for  older  patients?  In  the  large  material  at  the 
author's  disposal  he  has  often  asked  himself  this  question,  and  finally  the 
study  of  the  pathological  anatomy  led  him  to  a  method  for  the  operation 
of  old  bilateral  dislocation.  He  has  performed  the  operation  in  a  large 
number  of  cases  with  excellent  functional  results,  the  lordosis  improving 
and  the  waddling  gait  disappearing  partially  or  often  completely.  The 
following  technic  proved  most  serviceable:  The  joint  is  opened  through 
a  lateral  incision,  the  soft  parts  are  dissected  off  subperiosteally  from 
the  great  trochanter,  and  the  insertion  of  the  capsule  freed  from  the 
neck  of  the  femur,  so  that  the  head  can  he  freely  luxated  out  of  the 
wound.  The  head  is  removed  close  to  the  intertrochanteric  line  with 
a  tenon-saw,  the  "funnel"  of  the  capsule  is  then  stretched  tightly,  and 
its  posterior  wall  divided  in  the  middle  up  to  the  ilium,  its  attachment 
on  the  acetabular  margin  divided,  the  adhesions  separated,  which  always 
form  between  the  capsule  and  the  periosteum  of  the  ilium,  and  the  two 
flaps  of  the  capsule  excised.  A  free  periosteal  surface  is  thus  obtained 
upon  the  ilium,  against  which  the  sawed  surface  of  the  femur  is  planted 
by  abducting  the  thigh.  After-treatment:  iodoform  gauze  packing  and 
extension  or  plaster  splint.  The  patients  become  ambulant  at  the  end 
of  three  months  and  wrear  the  author's  supporting  corset  described 
above. 

This  method,  which  the  author  terms  a  pseudarthrosis  operation,  as 
he  seeks  to  obtain  fibrous  union  between  the  femur  and  pelvis,  he  can 
recommend  with  a  clear  conscience  as  excellent.  Kirmisson  was  the 
first  to  propose  subtrochanteric  osteotomy  for  old  unilateral  dislocation. 
The  author  has  repeatedly  performed  this  operation  as  an  oblique 
osteotomy  in  order  to  lengthen  the  limb  by  forcible  extension,  and  has 
in  fact  obtained  a  lengthening  of  from  1.5  to  2  inches,  and  was  well 
satisfied  with  the  functional  result. 


CHAPTER   XXIII. 

INJURIES  OF  THE  HIP. 
DISLOCATIONS  OF  THE  HIP. 

The  depth  of  the  cavity,  the  strength  of  the  capsule,  and  the  power  of 
resistance  of  the  large  muscles  and  of  the  neck  of  the  femur,  and  the 
infrequent  demands  made  upon  the  range  of  motion,  are  the  reasons 
for  the  great  infrequency  of  dislocations  of  the  hip-joint.  According  to 
Kronlein,  they  stand  below  those  of  the  shoulder  and  elbow  in  the  list 
with  a  frequency  of  only  2  per  cent.  Well-developed  men  from  the 
twentieth  to  the  fiftieth  year  are  most  commonly  affected,  occasionally 
children,  women,  and  old  men.  The  left  side  appears  to  be  injured 
somewhat  more  often  than  the  right.  According  to  Kneer,  of  132  recent 
dislocations  in  v.  Brims'  clinic,  71  were  in  the  left  side,  59  in  the  right 
side,  and  2  were  double.  Only  27  instances  of  double  dislocation  are 
known  up  to  the  present  time. 

On  account  of  its  deep  situation  the  articular  head  is  not  accessible 
to  direct  violence,  so  that  dislocation  is  indirect.  It  is  rarely  produced 
by  a  simple  blow  upon  the  trochanter  or  a  fall  upon  the  bended  knee 
or  upon  the  feet.  The  cause  is  usually  a  violent  and  sudden  exaggera- 
tion of  an  otherwise  physiological  movement,  the  femur  being  forced 
against  the  pelvis  or  the  pelvis  against  the  femur,  as  happens  by  falling 
from  a  great  height  or  being  run  over  by  a  heavy  wagon,  or  by  the 
impact  of  heavy  bodies  upon  the  hip-joint,  as,  for  example,  in  being 
buried  under  a  mass  of  earth  or  stone,  etc. 

It  is  always  necessary  that  the  limit  of  motion  should  be  reached  and 
the  greatest  width  of  the  head  overreach  the  acetabular  margin.  The 
cartilaginous  rim  of  the  cavity  and  the  check  ligaments  thus  form  a 
fulcrum  against  the  neck  of  the  femur,  the  femur  representing  the  long 
or  power  arm,  the  head  the  short  or  weight  arm  of  the  lever.  By  the 
action  of  the  long  arm  the  head  is  forced  in  the  opposite  direction 
against  the  capsule,  tears  it,  and  slips  out  over  the  margin  of  the  cavity. 
The  head  is  therefore  levered  out  of  the  cavity.  It  rarely  remains  partly 
in  contact  with  the  cavity  to  produce  an  incomplete  dislocation.  It  is 
doubtful  if  this  ever  occurs.  Once  having  left  the  cavity,  it  seldom 
retains  its  first  position  close  to  the  acetabulum,  but  is  impelled  by  the 
continuation  of  the  force  and  the  weight  of  the  limb  into  a  second  position 
and  held  there  by  the  uninjured  part  of  the  capsule,  especially  the 
iliofemoral  ligament.  The  tension  of  the  latter  usually  gives  a  typical 
position  to  the  dislocated  limb,  so  that,  according  to  Bigelow,  all  dislo- 
cations are  regular  in  which  the  ligament  is  intact,  irregular  in  which 
(416) 


DISLOCA  TIONS  01    THE  HIP.  417 

the  ligament,  the  strongest  in  the  body,  is  destroyed  by  extreme  violence, 
;i^,  for  example,  machinery  accidents. 

The  head  may  leave  the  cavity  behind,  in  front,  above,  or  below,  and 
the  following  dislocations  are  distinguished  according  to  its  position: 

1.  Dislocation  backward  (luxatio  postica  m-  retrocotyloidea) :  (a)  iliac 
dislocation;  (6)  sciatic  dislocation. 

2.  Dislocation  forward  (luxatio  antica  or  precotyloidea  :  '/  supra- 
pubic I  luxatio  pubica  or  iliopectinea  ;  b  infrapubic  I  luxatio  obturatoria 
and  luxatio  perinealis  . 

.:.   Dislocation  upward  (luxatio  supracotyloidea). 

4.   Dislocation  downward  (luxatio  infracotyloidea). 

Dislocation  backward  is  most  frequent.  Kneer'>  compilation  of  the 
statistics  of  Cooper,  Malgaigne,  Weber,  Hamilton.  Billroth,  and  v. 
Brims  gives  among  210  dislocations  160  backward  (70  per  cent,  and 
49  forward  44  per  cent.).  Of  backward  dislocations,  the  iliac  variety 
is  more  frequent  than  the  sciatic  (96  to  37,  Kneer).  The  two  varieties 
of  forward  dislocation  are  about  equally  frequent. 

Dislocation  Backward. — The  difference  in  position  of  the  head  in 
the  two  forms  of  backward  dislocation  is  not  great,  but  is  important 
practically.  The  two  forms  may  be  considered  together.  Backward 
dislocation  is  generally  caused  by  violence  forcing  the  lower  extremity 
into  a  position  of  flexion,  adduction,  and  inward  rotation.  Whether  the 
head  lies  above  upon  the  ilium  or  below  upon  the  ischium  depends  upon 
the  degree  of  flexion  and  inward  rotation;  the  action  is  either  that  the 
limb  makes  the  abnormal  movement,  the  pelvis  being  fixed,  or  the 
reverse.  In  the  former  case  there  are  three  possibilities:  First,  that  the 
limb  is  adducted,  rotated  inward,  and  only  slightly  flexed.  For  example, 
the  patient  falls  from  a  considerable  height  and  strikes  the  ground  with 
the  foot  gliding  inward,  or  falls  upon  the  side  with  the  leg  rotated  inward. 
The  force  is  thus  transmitted  to  the  head  of  the  femur,  which  in  turn  is 
forced  against  the  posterior-superior  or  posterior  part  of  the  capsule, 
and  if  the  force  is  sufficient  the  latter  is  torn;  the  head  passes  through 
the  capsule  toward  the  ilium.  The  tear  in  the  capsule  always  lies  above 
the  tendons  of  the  obturators,  which  may  also  be  torn.  The  head  then 
lies  either  between  the  obturator  interims  and  piriformis,  the  fleshy 
belly  of  the  latter  being  lacerated  or  torn  through,  or  the  head  passes 
beneath  the  pyriformis.  the  tendon  of  the  muscle  lying  on  the  neck  of 
the  femur,  the  head  resting  upon  the  gluteus  minimus,  lacerated  or  torn 
from  its  insertion  on  the  femur,  and  is  covered  by  the  edge  of  the  gluteus 
medius  and  the  gluteus  maximus.  I  Fig.  2o4. 1  The  iliofemoral  ligament 
is  put  on  the  stretch  chiefly  in  its  outer  arm;  the  anterior  and  inferior 
parts  of  the  capsule  are  intact.     I  Fi^.  2-V>. 

The  above  mechanism  is  rare.  As  a  rule,  there  is  a  more  pronounced 
flexion — in  fact,  hyperflexion  and  strong  inward  rotation,  the  conditions 
under  which  the  real  lever  action  comes  into  play.  It  is  rare  that  such 
dislocations  are  produced  by  merely  falling  on  the  ground;  usually 
marked  violence  is  necessary.  The  latter  is  most  frequently  applied  as 
a  heavy  weight,  which,  as,  for  example,  by  the  falling  of  a  great  mass 
Vol.  Ill— 27 


418 


INJURIES  OF  THE  HIP. 


of  earth,  transmits  the  rotary  movement  to  the  pelvis,  the  same  being 
struck  on  the  side  opposite  to,  and  being  rotated  forward  toward,  the 
side  of  the  dislocation.  The  dislocation  occurs  similarly  in  railroad 
accidents,  the  patient  being  thrown  out  of  the  car  and  remaining  sus- 
pended by  the  limb  affected.  In  this  case  the  cause  is  the  weight  of 
the  body  precipitated  forward  and  rotated. 

In  all  these  instances  the  mechanism  is  a  lever  action.  By  the  strong 
flexion,  adduction,  and  inward  rotation,  the  head  is  forced  against  the 
posterior-inferior  part  of  the  capsule,  the  extremity  becoming  a  two- 
armed  lever,  the  fulcrum  of  which  is  the  neck  of  the  femur  jammed 
against  the  upper-anterior  margin  of  the  cavity.  The  more  the  violence 
forces  the  long  lever  arm,  the  thigh,  in  the  above  direction,  the  more 


Fig.  254. 


Fig.  255. 


Position  of  the  head  in  iliac  dislocation. 


Position  of  the  Y-ligament  in  iliac  dislocation. 
(Bigelow.) 


the  short  arm  forces  the  weight  arm,  the  head,  backward  and  downward 
against  the  capsule,  till  the  latter  finally  yields.  The  tear  in  the  capsule 
therefore  lies  at  the  posterior-inferior  margin  of  the  cavity.  If  the  head 
protrudes,  it  does  not  remain  behind  and  below  the  cavity,  but  rises 
backward  and  upward  to  a  second  position  from  the  weight  of  the  limb 
or  the  effort  of  the  patient,  but  especially  from  the  continuation  of  the 
force  causing  marked  inward  rotation  of  the  thigh.  The  head  now  lies 
upon  the  inferior-posterior  surface  of  the  ischium  between  the  acetabular 
margin  and  the  lesser  sciatic  notch,  pushing  the  tendons  of  the  obturator 
internus  and  gemelli  before  it  till  they  slide  over  it,  and  the  tendon  of 
the  obturator  internus  is  caught  between  the  head  and  the  rim  of  the 
acetabulum,  the  gemelli  usually  being  torn.    The  head  then  lies  between 


DISLOCATIONS  OF  THE  III  J'. 


419 


_■ 


the  greater  and  lesser  sciatic  notch  or  at  the  lower  part  of  the  latter. 
It  presents  between  the  pyriformis  muscle,  covering  it  above,  and  the 
quadratus  femoris,  the  latter  being  slightly  torn.  This  is  its  position 
in  ischiatic  dislocation,  which  Bigelow  calls  "dislocation  beneath  the 
tendons/'  on  account  of  the  above  relation  to  the  rendon  of  the  obturator 
internus.      Fig.  256. 

The  tendon  of  the  obturator  interims  prevents  the  head  from  rising 
higher,  unless  it  is  torn,  which  happens  very  seldom.  According  to  the 
above  statistics,  the  head  is  usually  found  higher  upon  the  ilium,  but 
never  beyond  an  imaginary  line  drawn 
from  the  anterior-inferior  -pine  to  the 
upper  border  of  the  greater  sciatic 
notch.  A  higher  position  i-  prevented 
chiefly  by  the  tightly  stretched  inner 
arm  of  the  Y-ligament  and  the  i: 
posterior  wall  of  the  capsule.  There- 
fore the  iliac  dislocation  take-  place  in- 
directly and  secondarily,  the  head  hav- 
ing the  same  relation  to  the  surrounding 
muscles  as  in  the  previously  described 
direct  dislocation,  with  the  exception 
that  the  outward  rotator-  are  torn.  The 
dislocation,  therefore,  named  according 
to  its  origin,  is  termed  ilioischiatic. 

Various  important  practical  patholo- 
gico-anatomical  details  should  be  men- 
tioned. There  i-  not  infrequently  a 
fracture  of  the  acetabular  margin  at 
the  point  of  exit  of  the  head:  the  car- 
tilage may  he  loosened  from  the  under- 
lying bone;  there  may  be  a  star-shaped  position  of  the  head  ^  ^^  dislocation- 
fracture    of     the    floor   of    the    cavity. 

The  capsule  may  be  torn  triangularly  or  transversely  from  the  margin 
or  split  longitudinally  from  the  margin  to  the  trochanter.  The  tear  is 
very  seldom  at  the  insertion  on  the  neck  of  the  femur.  Sometimes 
the  entire  posterior  portion  is  separated  from  the  margin.  If  the  lateral 
portions  are  intact,  they  project  in  front  of  the  head  and  are  stretched 
tightly  between  the  posterior  margin  of  the  cavity  and  the  neck. 

The  Y-ligament  is  never  injured  in  the  regular  form,  thus  explain- 
ing its  great  significance  in  this  dislocation  in  being  able,  alone,  to 
hold  the  head  in  its  false  position.  In  the  ischiatic  variety  its  inner 
arm  is  stretched  chiefly;  in  the  iliac  variety,  mainly  the  outer  arm.  The 
ligamentum  teres  is  usually  ruptured,  but  may  be  torn  out  of  the  depres- 
sion on  the  head  or  torn  off  with  a  piece  of  the  head.  Braun  recently 
described  a  specimen  in  which  the  fracture-line  ran  from  above  down- 
ward through  the  head  of  the  femur,  the  fragment  being  still  attached 
to  the  ligamentum  teres.  The  sciatic  nerve  may  lie  pushed  up.  stretched, 
or  torn  by  the  neck  of  the  femur.    The  gluteal  vessels  may  be  compressed 


420 


INJURIES  OF  THE  HIP. 


Fig.  257. 


or  torn.  The  muscles  inserted  on  the  anterior  surface  of  the  femur  are 
stretched  tightly,  especially  the  iliopsoas,  pectineus,  and  the  adductors. 
As  to  complications:  aside  from  severe  injuries,  such  as  fracture  of  the 
vertebrse  or  pelvis  and  injuries  of  the  viscera,  there  is  occasionally  frac- 
ture of  the  neck  of  the  femur  or  of  the  shaft,  or  bilateral  dislocation, 
the  latter  to  be  described  separately.  Kammerer  made  a  careful  com- 
pilation in  1889  of  19  cases  of  fracture  complicating  all  forms  of  hip 
dislocation.  Of  these,  13  were  of  the  shaft  of  the  femur,  6  of  the 
neck;  12  accompanied  backward  dislocation,  2  downward  and  forward 
dislocation,  and  5  forward  and  upward  dislocation. 

Symptoms. — Picturing  to  one's  self  clearly  the  position  of  the  head 
in  iliac  and  ischiatic  dislocation  from  a  study  of  the  above-mentioned 
points  or  of  a  prepared  pelvis,  and  remembering  that  the  head  never 
ascends  actually  onto  the  surface  of  the  ilium,  it  will  be  obvious  at  once 
that  the  two  forms  show  no  great  clinical  dif- 
ferences. In  both  cases  the  limb  is  flexed,  ad- 
ducted,  rotated  inward,  and  shortened,  the  degree 
of  dislocation  alone  distinguishing  the  two  forms. 
In  the  iliac  form  (Fig.  257)  the  foot  is  rotated 
inward  and  supported  upon  the  toes  of  the  other 
foot  if  the  patient  stands.  The  flexion  of  the 
hip,  which  is  always  present,  is  compensated  by 
the  inclination  of  the  pelvis  and  lateral  curva- 
ture of  the  lumbar  vertebrae  until  the  sole  of  the 
foot  touches  the  ground.  In  the  dorsal  recum- 
bent position  the  flexion  is  greater,  the  foot  lying 
across  the  other  ankle.  In  the  ischiatic  form  the 
flexion  and  inward  rotation  are  greater.  In 
standing,  the  foot  projects  forward  beyond  the 
other  and  is  brought  to  the  ground  with  difficulty. 
Recumbent,  the  flexed  knee  crosses  the  other 
thigh,  its  inner  border  resting  on  the  front  of  the 
latter  above  the  patella.  The  shortening  is  ap- 
parent and  real;  apparent  from  the  elevation  of 
the  pelvis  in  the  effort  to  correct  the  adduction; 
real  from  the  upward  displacement  of  the  head 
J)  I  on  the  pelvis,  the  tip  of  the  trochanter  being  from 
W^^W?  0.75  to  2  inches  above  its  normal  position  in 
iliac  dislocation.  (Bigei.w.)  the  Roser-Nelaton  line.  The  lines  connecting 
the  anterior-superior  spine,  tuber  ischii,  and  the 
great  trochanter  form  a  triangle,  the  apex  pointing  backward  and  up- 
ward. The  distance  from  the  anterior-superior  spine  to  the  tip  of  the 
internal  malleolus  is  shortened,  the  shortening  being  greater  in  the  iliac 
than  in  the  ischiatic  form. 

The  deformity  of  the  hip  is  equally  striking.  The  hip  is  broader, 
the  great  trochanter  rotated  inward  and  forward,  stretching  the  fascia 
lata  outward.  In  lean  subjects  the  hip  is  fuller,  the  gluteal  fold  higher. 
The  head  may  be  felt  as  a  hard  rounded  body  deep  among  the  hip 


DISLOCATIONS  OF  THE  Jlir.  421 

muscles;  in  stout  people  it  will  be  necessary  to  rotate  the  thigh  to  identify 
the  head  by  its  movements.  The  normal  resistance  is  lacking  in  the 
groin;  rarely  the  contour  of  the  hip  is  entirely  obliterated  by  subcu- 
taneous extravasation.  The  almost  complete  fixation  of  the  head  is  (h\e 
to  the  action  of  the  Y-ligament  and  intact  part  of  the  capsule.  Passive 
abduction  and  outward  rotation  are  impossible,  flexion  and  adduction 
less  so,  active  motion  impossible.  Extension  and  abduction  are  also 
impossible.  There  is  an  elastic  resistance  to  all  attempts  at  motion. 
In  youthful  patients  there  is  not  infrequently  temporary  retention  of 
urine  from  the  severe  violence  and  concussion  of  the  pelvis.  The 
subjective  symptoms  are  comparatively  slight.  The  pain  is  intense, 
and  compression  of  the  sciatic  nerve  causes  tingling  and  burning  sen- 
sations radiating  to  the  foot,  or  severe  sciatica.  In  extremely  rare 
cases  the  Y-ligament  is  torn  and  an  irregular  dislocation  produced, 
the  limb  being  rotated  outward  by  its  own  weight. 

Diagnosis. — From  the  above  the  diagnosis  is  simple.  Mistakes  are 
hardly  possible,  although  the  condition  may  be  confused  wTith  contusion 
of  the  joint  if  there  is  much  swelling,  or  with  the  rare  fracture  of  the 
neck  with  inward  rotation.  The  differential  points  will  be  discussed 
later.  In  all  doubtful  cases  examination  under  anaesthesia  will  help. 
The  flexion,  adduction,  and  inward  rotation  are  greater  in  the  ischiatic 
than  in  the  iliac  form.  Complicating  fracture  of  the  acetabular  margin 
usually  makes  reduction  easier,  and  may  give  crepitus;  it  favors  a 
recurrence.  Simultaneous  fracture  of  the  neck  is  very  rare;  the  limb 
is  shortened  and  rotated  outward,  and  the  head  found  beneath  the 
gluteals. 

Prognosis. — Recent  dislocations,  properly  handled,  generally  give  a 
good  prognosis;  usually  no  derangement  is  left,  habitual  dislocation  is 
extremely  rare  and  only  occurs  with  simultaneous  fracture  of  the  ace- 
tabular rim.  Some  weakness  usually  persists  for  from  four  to  six  weeks 
on  account  of  the  muscular  atrophy  and  occasional  pain.  The  loss  in 
earning-efBciency  of  such  a  patient  is  estimated  at  about  25  per  cent. 
The  dislocation  becomes  old  very  soon,  and  although  there  are  single  in- 
stances in  which  reduction  was  possible  after  years,  complete  recovery  is 
usually  impossible  at  the  end  of  a  few  weeks.  The  head  generally  forms 
a  new  joint  for  itself,  often  very  complete.  The  shortening  and  inward 
rotation,  however,  are  a  great  hindrance  in  walking,  so  that  crutches  are 
always  necessary.  Exceptionally  the  inward  rotation  diminishes  in  time, 
but  the  patients  walk  with  a  pronounced  limp  and  tire  easily.  The  limb 
is  always  more  or  less  atrophic,  and  pressure  of  the  dislocated  head 
upon  the  sciatic  nerve  may  produce  continuous  and  annoying  neuralgia. 

The  old  cavity  fills  in  with  fibrous  tissue  and  in  time  is  entirely  oblit- 
erated, v.  Volkmann  found  a  strip  of  muscle  over  the  cavity  wTith  fibrous 
changes  on  its  upper  surface  two  months  after  dislocation;  MacCormac 
saw  a  cavity  entirely  filled  with  fibrous  tissue;  Que'nu  observed  a  new 
cavity  and  capsule  of  fibrocartilaginous  consistence;  Nicoladoni,  a  new 
strong  dense  capsule  and  a  cavity  covered  in  spots  with  fibrocartilage; 
Niehaus,  a  new  capsule  almost  entirely  ossified.     The  complete  new 


422  INJURIES  OF  THE  HIP. 

formation  of  a  ligamentum  teres,  as  demonstrated  experimentally  and 
reported  by  R.  Volkmann,  is  interesting.  The  head  of  the  femur  loses 
its  normal  form,  is  worn  off  where  it  articulates  with  the  new  cavity,  and 
loses  its  cartilage  elsewhere. 

The  evil  consequences,  such  as  acute  suppuration  and  putrefaction 
of  the  joint,  resulting  in  former  years  from  violent  and  rough  reduction 
methods,  are  hardly  to  be  feared  at  the  present  time.  The  etiology  and 
anatomy  of  dislocations  are  so  well  known  to-day  that  surgeons  do  not 
dread  reduction  like  their  predecessors.  If  done  properly,  it  usually 
presents  no  difficulties.  Fortunately  the  number  of  cases  is  few  in 
which  the  rational  procedure  fails,  and  these  are  the  cases  in  which 
there  is  an  insurmountable  hindrance  to  reduction:  fragments  of  bone 
lodging  in  the  cavity;  the  ligamentum  teres  may  tear  a  fragment  from 
the  head  and  lie  with  it  in  the  cavity;  a  piece  of  the  acetabular  margin 
may  be  broken  off  and  be  pushed  into  the  cavity  by  the  head  every  time 
reduction  is  attempted;  a  piece  of  the  trochanter  torn  off  with  the 
capsule  attached  to  it  may  be  caught  between  the  head  and  the  cavity; 
a  fragment  of  the  cotyloid  cartilage  may  be  broken  off  from  the  bone 
and  interposed  between  the  head  and  the  cavity.  The  head  may  be 
buttonholed  through  the  outward  rotators,  but  it  is  hardly  conceivable 
that  the  hindrance  cannot  be  overcome  by  the  appropriate  procedure. 
This  cannot  be  said  of  the  hindrance  occasionally  caused  by  tears  in 
the  capsule;  the  rent  may  be  so  narrow  that  the  head  pushes  the  capsule 
in  front  of  it,  as  demonstrated  beyond  question  by  Gelle;  or  a  torn 
portion  of  the  capsule  may  lodge  in  the  cavity  and  so  prevent  reduction. 

Treatment. — As  reduction  is  painful  and  the  large  muscles  Alive  to  be 
relaxed,  anaesthesia  is  preferable.  The  fixation  of  the  pelvis  can  be 
accomplished  in  two  ways:  either  by  pressure  upon  the  anterior  superior 
spine  or  by  Gersuny's  method.  The  latter  consists  in  flexing  the  other 
limb  at  the  knee  and  thigh  and  pressing  the  knee  firmly  against  the  chest 
while  the  operator  manipulates  the  dislocated  thigh  with  one  hand  upon 
the  knee,  the  other  at  the  ankle.  Reduction  is  accomplished  without 
violence  or  roughness  by  methods  deduced  from  the  study  of  the  etiology 
and  the  pathological  anatomy,  and  which  may  be  termed  anatomico- 
physiological  procedures.  There  are  only  two  methods  which  can  lay 
claim  to  this  name,  and  the  author  therefore  only  mentions  these  two: 
(1)  the  method  of  manipulation  proposed  by  Roser,  Busch,  Bigelow, 
and  Kocher,  and  in  which  the  author  follows  Kocher;  and  (2)  the 
lever  method,  recommended  especially  by  Middeldorpf  and  used  by 
other  authors. 

Kocher's  Method. — The  thigh  is  first  rotated  inward  still  further, 
flexed  to  a  right  angle,  direct  traction  exerted  in  the  axis  of  the  flexed 
thigh,  and  the  limb  then  rotated  outward  and  extended.  The  inward 
rotation  relaxes  the  capsule  and  Y-ligament  and  lifts  the  head  off  from 
the  posterior  surface  of  the  pelvis.  Flexion  to  a  right  angle  brings  the 
head  down  behind  the  intact  part  of  the  capsule  to  opposite  the  tear. 
Inward  rotation  and  adduction  of  the  thigh  are  meanwhile  maintained 
without  using  any  force.     One  should  avoid  violent  flexion,  which  may 


DISLOCATIONS  OF  THE  HIP.  423 

draw  the  head  forward  over  the  lower  margin  of  the  cavity  and  produce 
a  dislocation  forward  upon  the  obturator  foramen.  The  traction  upward 
puts  the  Y-ligament  and  the  capsule,  chiefly  its  posterior  part,  on  the 
stretch  and  lifts  the  head  to  the  level  of  the  acetabular  margin,  the 
trochanter  being  fixed  by  the  tension  of  the  Y-ligament,  and  the  outward 
rotation  then  forces  the  head  into  the  cavity. 

Middeldorpf's  Leveb  Method. — The  movements  are  strong 
flexion,  abduction,  and  rotation  outward.  Flexion  levers  the  head  away 
from  the  pelvis  and  brings  it  opposite  to  the  tear  in  the  capsule;  abduc- 
tion makes  tense  the  outer  limb  of  the  iliofemoral  ligament  and  presses 
the  neck  of  the  femur  or  the  trochanter  against  the  edge  of  the  cavity, 
and  on  this  fulcrum  the  outward  rotation,  following,  levers  the  head 
into  the  cavity. 

In  both  methods  there  is  a  characteristic  sound  as  the  head  slips  into 
the  cavity.  Motion  is  then  free  in  all  directions.  The  beginner  should 
be  careful  not  to  produce  an  obturator  dislocation.  Both  methods  are 
equally  good  and  practicable.  The  second  is  particularly  useful  for 
older  injuries,  but  great  care  should  be  exercised  in  abducting  and 
rotating  outward  not  to  fracture  the  neck,  a  possibility,  especially  in 
the  aged,  which  has  happened  to  the  best  surgeons.  It  may  be  avoided 
by  carrying  out  all  movements  slowly  and  steadily,  not  by  jerks. 

If  reduction  is  impossible  and  one  is  obliged  to  conclude  that  there 
is  an  insurmountable  hindrance,  as  mentioned,  the  attempt  should  be 
abandoned  unless  an  open  reduction  can  be  performed  with  aseptic 
precautions,  as  accomplished  successfully  by  v.  Volkmann.  Recent  dis- 
locations complicated  by  fracture  of  the  neck  or  of  the  shaft,  if  non- 
reducible, require  operation.  If  on  exposing  the  hip-joint  for  fracture 
of  the  neck  reduction  of  the  head  is  impossible,  the  experienced  "Asep- 
tiker"  may  resect  the  head,  place  the  end  of  the  shaft  in  the  cavity, 
and  with  the  limb  abducted  apply  an  adhesive  plaster  extension  splint 
with  weights.  The  less  experienced  should  attempt  to  secure  union  of 
the  fracture  in  the  most  favorable  position  and  the  formation  of  a  new 
joint. 

One  may  try  to  reduce  old  dislocations  by  the  lever  method,  after 
dividing  the  adhesions  as  much  as  possible,  by  rotating.  If  operation  is 
necessary:  after  dividing  all  shortened  soft  parts,  removing  all  interposed 
ligaments,  and  exposing  and  cleaning  out  the  old  cavity,  the  head  is 
replaced.  This  has  been  successful  in  a  number  of  cases.  (R.  v.  Volk- 
mann, Drehmann,  Endlich,  and  Payr.)  Another  method  is  to  obtain 
a  new  joint,  and  later  restore  the  proper  attitude  of  the  limb  by  sub- 
trochanteric osteotomy.  Hoffa's  oblique  osteotomy  is  most  advisable, 
as  the  false  position  of  the  limb  can  thus  be  compensated  and  the 
shortening  overcome  at  the  same  time  to  a  great  extent. 

Resection  of  the  head  of  the  femur  should  be  done  only  as  a  last 
resort  in  stubborn  cases.  So  far  it  has  been  performed  in  18  cases, 
according  to  Kirn,  Bloch,  and  Ostermayer,  with  13  recoveries,  and  in 
part  with  excellent  functional  results.  If  one  is  unfortunate  enough  to 
fracture  the  neck  in  attempting  the  reduction  of  old  dislocations,  if  the 


424 


INJURIES  OF  THE  HIP. 


Fig.  25S. 


fracture  is  extracapsular  an  extension  splint  should  be  applied;  if  intra- 
capsular, removal  of  the  head  is  indicated,  as  experience  has  taught 
that  the  head  easily  becomes  necrotic  on  account  of  its  poor  blood-supply. 
The  after-treatment  consists  in  applying  an  ice-bag  to  the  hip  and 
immobilizing  for  a  short  period — two  to  three  weeks  if  uncomplicated, 
six  weeks  if  there  is  a  fracture  of  the  acetabular  margin — otherwise 
recurrence  takes  place  easily.  After  the  patient  is  about,  massage, 
electricity,  and  careful  exercise  should  follow. 

Dislocation  Forward. — Whereas  backward  dislocation  results  from 
violence  flexing,  adducting,  and  rotating  the  thigh  inward,  forward 
dislocation  results  from  violence  abducting  and  rotating  the  thigh 
outward  while  it  is  flexed  or  extended.  The  abnormal  movement  may 
be  on  the  part  of  the  pelvis  or  the  thigh.  The  tear  in  the  capsule  through 
which  the  head  emerges  is  either  at  the  anterior-superior  or  anterior- 
inferior  margin  of  the  cavity,  and  the 
head  comes  to  lie  upon  the  corresponding 
surface  of  the  os  pubis. 

Suprapubic  Dislocation. — The  cause  of 
pubic  dislocations  is  rarely  direct  vio- 
lence, but  usually  some  force  bending  the 
body  backward  while  the  thighs  are  ab- 
ducted and  rotated  outward,  as,  for  ex- 
ample, in  children,  a  "blow  from  a  swing 
pushing  the  body  backward  ;  similarly 
in  adults  by  the  descent  of  a  heavy  body 
upon  the  chest,  or  by  being  caught  in 
the  spokes  of  a  wheel,  or  doubled  back- 
ward in  wrestling,  catching  the  foot  in  a 
hole  in  walking  or  running,  the  body 
being  bent  backward  to  check  the  fall. 
In  every  case  it  is  a  lever  action.  The 
neck  of  the  femur  is  pressed  against 
the  fulcrum  established  by  the  lower 
back  margin  of  the  cavity.  The  head, 
the  weight  lever  arm,  is  forced  forward 
and  upward  against  the  capsule  and 
tears  it  at  its  weak  part  in  front  of  and  to 
the  inner  side  of  the  iliofemoral  ligament. 
The  position  of  the  head  upon  the 
os  pubis  may  vary,  but  is  most  frequently  upon  the  pubic  spine  to 
the  inner  side  of  the  anterior-inferior  spine  at  the  point  of  junction  of 
the  ilium  and  the  horizontal  ramus  of  the  os  pubis,  the  iliopectineal 
eminence.  If  it  lies  a  little  more  outward  directly  beneath  the  spine, 
it  is  termed  a  luxatio  subspinosa;  if  it  lies  more  in  the  middle  of  the 
pubic  bone  or  farther  to  the  inner  side  of  the  pubic  spine,  it  is  a  pubic 
dislocation. 

In  regard  to  the  pathologico-anatomical  details:  The  head  is  held 
firmly  against  the  bone  by  the  pressure  of  the  iliopsoas  and  tense  fascia 


Suprapubic  dislocal  ion. 


DISLOCATIONS  OF  THE  HIP. 


425 


lata  running  over  it  or  over  its  neck.  (Fig.  258.)  It  presses  slightly 
against  the  groin  at  the  internal  ring.  The  great  trochanter  lies  in  the 
acetabulum.  Lauenstein  in  one  instance  on  autopsy  found  the  great 
trochanter  torn  off  by  muscular  traction;  in  this  case  the  neck  was 
supported  against  the  upper  margin  of  the  cavity.  The  capsule  either 
tears  close  to  the  neck,  the  torn  flap  attached  to  the  acetabular  margin 
being  forced  into  the  cavity,  or  it  is  torn  off  directly  in  front  close  to  its 
marginal  attachment  so  that  the  neck  is  buttonholed  between  the  capsule 
and  the  cartilage.  The  Y-ligament  is  intact,  the  inner  arm  less  tense 
than  the  outer,  the  latter  being  pulled  backward  with  the  great  trochanter 
toward  the  cavity.     (Fig.  259.)     The  crural  nerve  runs  over  the  neck; 


Fig.  259. 


Fig.  200. 


Pubic  dislocation. 


Pubic  dislocation.    (Bigelow.) 


the  femoral  vessels  are  displaced  inward  toward  the  symphysis.  The 
artery  lying  between  the  head  and  the  os  pubis  may  be  compressed. 
Rarely  the  large  vessels  lie  over  the  arch  of  the  head  and  are  naturally 
stretched  severely.  The  pectineus  is  usually  torn  laterally  or  pushed 
and  bent  toward  the  symphysis;  the  three  gluteals  are  relaxed,  their 
insertion  drawn  inward  with  the  trochanter.  The  outward  rotators 
together  with  the  back  part  of  the  capsule  are  displaced  inward,  forced 
into  the  cavity  by  the  trochanter,  and  either  greatly  stretched  or  torn 
with  the  exception  of  the  obturator  externus. 

Symptoms. — The  symptoms  are  significant.  (Fig.  260.)  The  thigh 
is  usually  extended,  abducted,  and  rotated  outward.  The  abduction  is 
least  in  the  iliopectineal  form,  the  thigh  being  almost  parallel  to  the 


426  INJURIES  OF  THE  HIP. 

other.  The  more  the  head  approaches  the  middle  line,  the  more  marked 
are  the  abduction  and  the  flexion.  If  the  flexion  is  not  noticed  at  first, 
it  is  because  it  is  corrected  by  the  inclination  of  the  pelvis.  The  short- 
ening is  always  real,  the  head  lying  above  the  cavity,  although  the  limb 
may  appear  to  be  lengthened  on  account  of  the  abduction.  Beneath 
Poupart's  ligament,  near  the  anterior-inferior  spine  or  the  pubic  spine, 
can  be  felt  the  rounded  prominence  of  the  head,  verified  by  rotation. 
To  its  inner  side  lies  the  femoral  artery;  the  latter  lies  partially  upon 
the  head  and  transmits  a  distinct  thrill  to  the  finger.  Active  motion 
is  impossible;  passively  flexion,  adduction,  and  inward  rotation  are  also 
impossible;  abduction  and  outward  rotation  are  possible  to  a  very  slight 
extent  on  account  of  the  support  of  the  tense  intact  back  part  of  the 
capsule  and  the  inner  arm  of  the  Y-ligament.  Walking  is  sometimes 
possible,  apparently  because  the  neck  is  supported  by  the  iliofemoral 
ligament  and  the  head  against  the  anterior-inferior  spine.  If  the  crural 
nerve  is  stretched,  there  may  be  intense  pain  radiating  into  the  thigh,  or 
numbness,  or  a  feeling  of  heaviness.  Occasionally  there  is  retention  of 
urine.  The  hip  is  flattened  and  the  gluteal  fold  obliterated.  The  normal 
prominence  of  the  trochanter  is  absent.  The  dislocation  may  be  mis- 
taken for  fracture  of  the  neck,  but  not  if  the  differential  points  to  be 
given  later  are  compared. 

Prognosis. — The  prognosis  is  relatively  the  best  of  all  dislocations  of 
the  hip.  Neuralgic  pains  in  the  crural  nerve  may  persist  for  some  time 
after  reduction.  Even  if  unreduced  the  use  of  the  limb  may  be  recovered 
if  a  new  joint  is  formed  on  the  pubic  bone  or  the  head  is  supported 
against  the  inferior  spine.  Flexion  at  the  hip  and  knee  is  usually  lost 
or  diminished  on  account  of  the  interference  with  the  function  of  the 
flexors  of  the  leg  arising  from  the  tuber  ischii. 

Treatment. —  Kocher's  Method. —  The  thigh  is  hyperextended, 
flexed,  with  pressure  upon  the  head,  and  rotated  inward.  By  hyperex- 
tension  the  head  is  lifted  off  the  bone  in  case  the  outward  rotation  and 
abduction  are  marked.  The  femur  forms  a  lever,  the  shaft  being  the 
long  arm,  the  neck  and  head  the  short  arm,  the  fulcrum  the  trochanter 
held  by  the  intact  portion  of  the  capsule.  The  head  having  been  freed, 
is  pushed  by  direct  pressure  toward  the  cavity  to  prevent  it  from  sliding 
upward  as  the  iliofemoral  ligament  is  relaxed  in  flexing.  Flexion  is 
continued  to  a  right  angle;  the  lower  back  part  of  the  capsule  is  thus 
put  on  the  stretch  and  the  head  rotated  inward  into  the  cavity. 

Middeldorpf's  Lever  Method. — It  consists  in  hyperextension, 
strong  flexion,  adduction,  and  inward  rotation.  The  purpose  of  hyper- 
extension is  as  above.  Flexion  is  carried  to  an  acute  angle;  the  head 
thus  slides  downward  upon  the  upper  margin  of  the  cavity.  Adduction 
brings  the  neck  against  the  margin  of  the  cavity,  and  upon  this  fulcrum 
the  head  is  levered  into  the  cavity  by  inward  rotation. 

In  both  methods  the  patient  lies  at  the  edge  of  the  table  to  permit  of 
hyperextension . 

Infrapubic  Dislocation. — Abduction  and  outward  rotation  of  the  thigh 
are  essential  for  the  production  of  this  dislocation.     If  the  thigh  is 


DISLOCATIONS  OF  THE  11 IP. 


427 


abducted  and  rotated  outward,  a  simple  blow  from  the  side  is  sufficient 

to  force  the  head  over  the  front  margin  of  the  cavity.  Such  direct 
violence  is  rare;  usually  the  thigh  is  flexed  strongly  and  permits  of  the 
lever  action.  The  thigh  is  abducted,  rotated  outward,  and  flexed;  the 
upper  outer  margin  of  the  acetabulum  forms  a  fulcrum;  the  head  is 
forced  against  the  front  lower  part  of  the  capsule,  tears  it,  and  advances 
directly  to  the  obturator  foramen  (obturator  dislocation).  If  the  flexion 
is  pronounced,  the  head  may  descend  to  the  ramus  of  the  ischium  and 
lie  upon  the  perineum  (perineal  dislocation).  If  the  violence  produces 
inward  rotation  instead  of  abduction  and  outward  rotation  at  the 
moment  when  the  head  of  the  strongly  flexed  limb  lies  at  the  projecting 


Fig.  201. 


Fig.  262. 


Obturator  dislocation.    (Bigelow.) 


border  of  the  ischium,  the  head  may  glide  backward  along  the  lower 
margin  of  the  cavity  to  the  ischium  (ischiatic  dislocation).  The  author 
has  seen  that  the  reverse  process  can  occur  in  reducing  a  backward 
dislocation,  the  head  being  pushed  forward  by  flexing  too  strongly, 
producing  a  secondary  obturator  dislocation. 

The  causes  are  numerous:  a  heavy  weight  falling  upon  the  back  while 
the  body  is  bent  forward  and  the  thighs  abducted;  a  fall  from  a  height 
with  the  thighs  spread;  from  the  thigh  being  held  between  girders,  while 
the  body  falls  laterally;  a  fall  from  a  horse  with  the  foot  caught  in  the 
stirrup,  etc.  The  head  lies  upon  the  obturator  foramen  (Fig.  261 )  usually 
at  the  lower  part,  covering  about  one-half  or  two-thirds  of  the  membrane. 


428  IS  JURIES  OF  THE  HIP. 

It  may  compress  the  obturator  vessels  and  nerve;  sometimes  the  external 
obturator  muscle  lies  under  the  head,  but  is  usually  stretched  tightly 
over  it  with  the  adductor  longus  and  brevis  and  may  be  torn.  The 
lower  part  of  the  head  rests  upon  the  upper  part  of  the  adductor  magnus. 
The  posterior  surface  of  the  great  trochanter  lies  directly  in  the  cavity 
and  pulls  the  attached  gluteals  inward.  The  front  upper  part  of  the 
capsule  is  always  intact  and  stretched  over  the  neck,  preventing  the  head 
from  rising  and  forming  a  suprapubic  dislocation.  This  front  upper  part 
of  the  capsule  with  the  iliofemoral  ligament  gives  the  limb  its  typical  atti- 
tude. The  back  part  of  the  capsule  is  not  tense.  The  Y-ligament  is 
stretched  tightly.  (Fig.  2G1.)  Its  inner  arm  rotates  the  femur  outward 
and  is  rarely  torn.  In  the  latter  event  the  outward  rotation  is  less.  In 
perineal  dislocation  the  tear  in  the  capsule  is  usually  larger.  In  a  speci- 
men of  Bigelow's  the  outer  arm  of  the  Y-ligament  was  also  torn;  the 
femoral  vessels  ran  over  the  neck  with  the  crural  nerve;  the  pectineus 
and  adductor  brevis  lay  between  the  neck  and  the  ischium. 

Symptoms. — The  characteristic  symptoms  of  obturator  dislocation  are 
moderate  flexion  (about  35  degrees),  abduction,  outward  rotation,  and 
shortening  (Fig.  262) ;  they  are  more  distinct  if  the  patient  is  recumbent. 
The  limb  is  then  abducted,  flexed  at  the  hip  and  knee,  is  supported  upon 
the  outer  border  of  the  foot  and  is  shortened.  If  the  patient  stands, 
flexion  is  less  pronounced  as  the  spine  curves  forward  and  the  pelvis 
inclines  forward  and  to  the  side,  thus  compensating  the  abduction. 
The  limb  therefore  appears  lengthened,  but  is  actually  shortened.  It 
has  been  repeatedly  conceived  that  the  limb  must  be  lengthened  in  that 
the  head  is  lower  on  the  obturator  foramen  than  in  its  cavity.  Careful 
measurements  from  the  anterior  superior  spine  to  the  tip  of  the  external 
malleolus  verify  the  shortening.  Malgaigne  found  a  shortening  of  7 
lines;  Treub,  1^  inches;  Lauenstein,  2  inches. 

The  outward  rotation  may  be  masked  by  the  inward  rotation  of  the 
foot.  (Fig.  262.)  The  patient  turns  the  foot  forward,  with  the  toes 
upon  the  ground,  the  heel  elevated,  the  knee  flexed,  and  the  hip-joint 
abducted  and  rotated  outward,  the  abduction  and  flexion  being  propor- 
tional to  the  lowness  of  the  head.  The  buttock  is  flattened,  the  normal 
prominence  of  the  trochanter  is  lacking,  and  the  hip  is  widened  and 
fixed.  Motion  is  impossible  with  the  exception  of  perhaps  slight  abduc- 
tion and  flexion.  The  head  produces  slight  bulging  of  the  soft  parts  in 
the  region  of  the  falciform  fold  of  the  fascia  lata,  and  can  be  recognized 
if  the  adductors  are  not  too  strongly  developed.  One  often  feels  merely 
an  indistinct  sense  of  something  rolling  in  rotating  the  thigh.  The  head 
can  always  be  felt  distinctly  per  rectum.  The  patient  is  often  able  to 
walk  some  distance  after  the  injury,  apparently  because  the  head  obtains 
a  good  support  against  the  obturator  foramen  and  the  intact  upper  part 
of  the  capsule.  Pressure  upon  the  obturator  and  crural  nerves  often 
causes  intense  pain  or  at  least  numbness  in  the  limb. 

Perineal  dislocation  has  so  far  been  seen  only  9  times.  (J.  Riedinger, 
1892.)  It  is  easily  recognized.  (Fig.  263.)  The  limb  is  in  a  position 
of  maximal  abduction  and  maximal  flexion,  the  former  being  dependent 


DISLOCATIONS  OF  THE  II IP. 


429 


Perineal  dislocation.      (Bipelow.) 


upon  the  latter  on  account  of  the  check  action  of  the  iliofemoral 
ligament.  The  thigh  is  almost  at  a  right  angle  to  the  body.  The  leg, 
flexed  sharply,  rests  upon  the  outer  border  of  the  foot.    It  is  impossible 

to  stand  erect  upon  both  feet,  as  the  pelvis  cannot  compensate  the 
deformity.  The  head  can  he  felt  distinctly  projecting  behind  the  scrotum 
or  beneath  the  adductors. 

The  differentia]  diagnosis  of  obturator  dislocations  from  fracture  of 
the  neck  will  be  mentioned  later. 

Prognosis. — The  prognosis  of  unreduced  obturator  dislocations  is  not 
unfavorable.  The  head  forms  a  good  nearthrosis  in  its  new  position 
and  the  patient  may  walk  very  well. 

The  head  is  gradually  pushed  up-  l'I<;-  2G3. 

ward  by  the  body-weight  and  the 
limb  assumes  an  attitude  similar 
to  that  in  suprapubic  dislocation; 
the  knee  is  hyperextended  to  make 
both  limbs  of  the  same  length  : 
otherwise  the  dislocation  is  the 
same  as  the  pubic  form. 

Treatment.  —  Kocher's  Ra- 
tional Mkthod.  —  Flexion  to  a 
right  angle,  vertical  traction  in  this 
position,  and  strong  outward  rota- 
tion. Flexion  is  necessary  to  relax 
the  iliofemoral  ligament.  If  the  thigh  is  flexed  to  a  right  angle,  no 
part  of  the  capsule  is  tense.  To  utilize  the  tension  of  the  back  part  of 
the  capsule  in  order  to  rotate  about  a  fixed  point,  traction  is  now 
exerted  vertically.  By  rotating  the  thigh  forcibly  outward  the  posterior 
part  of  the  capsule  is  twisted  and  shortened,  the  outer  arm  of  the 
Y-ligament  is  put  on  the  stretch,  and  the  head  is  drawn  upward  and 
backward  into  the  cavity.  The  perineal  dislocation  can  often  be 
reduced  by  simple  downward  traction  combined  with  strong  outward 
traction  on  the  upper  part  of  the  thigh. 

Middeldorpf's  Lever  Method. — Flexion  to  a  right  angle,  adduc- 
tion, and  inward  rotation.  Flexing  the  thigh  in  the  given  position  relaxes 
the  capsule  and  the  Y-ligament  and  frees  the  head.  In  order  to  prevent 
the  head  meanwhile  or  during  subsequent  adduction  from  sliding  around 
outside  of  the  cavity  and  producing  an  ischiatic  dislocation,  the  limb  is 
drawn  upward  at  the  same  time  by  means  of  a  sling.  Adduction  brings 
the  head  to  the  cavity,  inward  rotation  levers  it  in.  For  the  treatment 
of  complications  and  old  dislocations  see  under  Backward  Dislocations. 

Dislocation  Downward. — Dislocation  directly  beneath  the  acetabu- 
lum is  very  rare.  The  tear  in  the  capsule  is  in  its  lower  pole.  The 
upper  surface  of  the  head  lies  upon  the  tuber  ischii,  supported  in  front 
and  to  the  inner  side  by  the  tense  adductors;  behind,  by  the  equally 
tense  flexors  of  the  knee.  The  iliopsoas,  pectineus,  and  Y-ligament  are 
also  stretched  tightlv.  The  dislocation  is  caused  by  forced  abduction 
without  rotation  of  the  thigh,  occasionally  by  a  direct  blow  from  above 


430 


INJURIES  OF  THE  HIP. 


Fig.  264. 


upon  the  flexed  thigh.  As  the  head  is  not  supported  by  the  tuber  ischii,  ir 
passes  readily  into  a  second  position,  ischiatic  dislocation,  by  abduction 
and  inward  rotation,  and  by  adduction  and  outward  rotation  to  an 
obturator  dislocation.  Occasionally  it  becomes  subcotyloid  instead  of 
ischiatic  or  obturator. 

Symptoms. — In  the  regular  form  with  the  Y-ligament  intact  the 
symptoms  are  unmistakable.  (Fig.  264.)  The  thigh  is  flexed  not  quite 
to  a  right  angle,  also  the  knee,  so  that  the  leg  hangs  against  the  thigh. 
The  thigh  can  be  easily  abducted  and  rotated  outward;  extension  is 
impossible;  the  other  movements  are  less  extensive;  rotation  is  freest. 
It  is  not  always  possible  to  feel  the  head  on  account  of  the  overhang 
muscles.  The  irregular  dislocation  which  is  accompanied  by  lacera- 
tion of  the  Y-ligament  gives  an  atypical 
attitude;  the  thigh  may  be  extended, 
rotated  inward  or  outward,  or  abducted. 
Prognosis. — The  prognosis  is  favorable 
as  reduction  is  easy.  In  irreducible 
irregular  dislocation  the  head  may  be 
supported  beneath  the  acetabulum  and 
motion  be  possible. 

Treatment.  —  Reduction  is  by  simple 
traction  in  the  given  direction  of  the 
thigh — namely,  of  flexion  and  abduction, 
and  finally  outward  rotation. 

Dislocation  Upward. — Dislocation  up- 
ward is  rare,  but  more  frequent  than  dis- 
location forward.  We  are  indebted  to 
Blasius  for  a  comprehensive  monograph 
based  on  23  cases  of  upward  disloca- 
tion. The  head  lies  either  upon  the  an- 
terior-inferior spine  or  below  it,  or  between  it  and  the  anterior-superior 
spine.  (Fig.  265.)  The  cause  is  flexion,  adduction,  and  outward  rota- 
tion, and  the  dislocation  is  therefore  to  be  regarded  as  a  variety  of 
iliac  dislocation,  except  that  the  final  motion  is  outward  instead  of 
inward  rotation.  The  capsule  is  torn  at  the  posterior  margin  of  the 
cavity.  The  Y-ligament  is  in  front  of  the  head  and  its  outer  arm  is 
stretched  tightly. 

Symptoms. — The  symptoms  may  be  mistaken  on  superficial  examina- 
tion for  those  of  iliopectineal  dislocation.  The  limb  is  extended, 
adducted,  rotated  strongly  outward,  and  shortened.  (Fig.  266.)  The 
head  can  be  felt  beneath  the  anterior-superior  spine.  The  shortening 
appears  greater  on  account  of  the  adduction.  Although  adduction  may 
be  sometimes  less  marked,  outward  rotation  is  always  so  pronounced 
that  the  foot  points  sideways  or  even  backward.  According  to  the  degree 
of  outward  rotation,  the  great  trochanter  is  displaced  either  backward 
or  more  to  the  side,  and  the  normal  site  of  the  trochanter  is  accordingly 
depressed  or  more  prominent.  The  axis  of  the  femur  is  apparently 
displaced  laterally,  giving  a  curved  outline  to  the  inner  surface  of  the 


Subcotyloid  dislocation.   (Bigelow.) 


DISLOCATIONS  OF  THE  ll u: 


431 


upper  pari  of  the  thigh.  The  buttock  is  relaxed,  broad,  and  flat,  the 
fold  elevated.  At  the  junction  of  the  hip  with  the  groin  and  perineum 
there  are  several  small  very  distinct  folds  of  skin.  Flexion  is  possible, 
to  a  slight  extent;  all  other  movements  impossible. 

Scriba  describes  a  subvariety  of  this  dislocation — luxatio  intrapelvica 
— in  which  the  head  could  be  distinctly  felt  through  the  abdominal  wall 
above  the  iliopectineal  line,  the  neck  in  the  iliac  fossa,  the  great  trochan- 
ter on  the  outer  portion  of  the  horizontal  ramus  of  the  pubis,  on  the 
anterior-inferior  spine.  The  thigh  was  flexed,  adducted,  and  rotated 
inward.  The  dislocation  was  caused  by  a  blow  upon  the  chest  from 
a  swing.  By  hyperextension  the  dislocation  was  transformed  into  an 
iliopectineal  dislocation  and  thus  reduced. 


Fig.  2G">. 


Fig.  266. 


Supracotyloid  or  supraspinous  dislocation.     (Bijrelow.) 


Prognosis. — The  prognosis  of  upward  dislocation  is  favorable  as  reduc- 
tion is  easy.  Old  dislocations  permit  of  good  function  as  the  head  is 
supported  against  the  anterior-superior  spine. 

Treatment. — Reduction  is  by  moderate  flexion,  adduction,  downward 
traction,  and  inward  rotation. 

Central  Dislocation. — By  central  dislocation  is  understood  an  intra- 
pelvic  displacement  of  the  head  through  the  fractured  acetabulum.  It 
is  caused  by  severe  violence  crushing  the  floor  of  the  cavity  and  com- 
pletely tearing  the  capsule.  There  are  usually  other  complicating 
fractures  of  the  pelvis  or  injuries  of  the  intestines. 


432 


INJURIES  OF  THE  HIP. 


Fig.  267. 


Symptoms. — The  symptoms  are  shortening  of  the  limb,  outward 
rotation,  and  fixation.  The  shortening  is  overcome  by  strong  traction, 
but  returns  immediately.     Katz  reports  11  cases,  6  of  which  died. 

Diagnosis. — The  diagnosis  is  made  from  the  ease  with  which  the 
shortening  is  overcome,  the  immediate  return  of  the  latter  on  releasing 
the  limb,  by  rectal  examination,  and  the  away. 

Treatment. — The  treatment  consists  in  reducing  and  applying  an 
extension  splint. 

Bilateral  Dislocations  of  the  Hip-joint. — In  1887  Niehaus  collected 
the  26  cases  of  simultaneous  dislocation  of  both  hip-joints  seen  up  to 
that   time.     Since  then  a  case  of   Niehaus'  and  2  from  the  clinics  of 

P.  v.  Brims  and  Schonborn,  bring  the 
number  up  to  29.  Among  these 
there  were  4  forward  dislocations 
(obturator),  6  backward,  and  the 
others  were  partly  backward  or  partly 
forward.  The  cause  was  either  the 
impact  of  a  heavy  body  or  blows  forc- 
ing the  body  violently  backward  or 
forward.  The  hip-joints  were  thus 
hyperextended  or  hyperflexed. 

Symptoms. — The  symptoms  were 
usually  very  clear.  Fig.  267  shows 
a  bilateral  backward  dislocation  in 
which  there  was  pronounced  promi- 
nence of  the  trochanters  and  lordosis. 
The  striking  feature  of  the  bilateral 
forward  dislocation  is  the  marked 
abduction  of  the  limbs.  In  Ebner's 
case  the  knees  were  6  inches  apart. 

Diagnosis. — The  diagnosis  is  not 
always  made  immediately.  Often  the 
dislocation  is  reduced  on  one  side 
and  the  other  recognized  by  the  fact 
that  the  limbs  are  not  parallel.  In 
Niehaus'  case  there  was  considerable 
swelling  about  the  pelvis,  which  was  regarded  as  an  indication  of 
bilateral  fracture  of  the  neck. 

Prognosis. — The  prognosis  is  relatively  good.  In  the  above  29  cases 
reduction  and  recovery  occurred  in  21,  4  remained  unreduced,  1  patient 
died  from  the  operation  for  resection  of  the  head,  another  in  shock. 

Treatment. — Reduction  of  one  dislocation  after  the  other  is  to  be 
performed  as  described  previously. 

Voluntary  Dislocation. — It  is  noteworthy  that  voluntary  dislocation 
is  rather  frequent  in  the  hip.  Perrin  collected  15  cases,  Hamilton  6 
from  English  and  American  literature.  Kronlein  cites  cases  of  Portal, 
Humbert  and  Jacquier,  Stanley,  Karpinski,  and  Peininger,  5  in  all. 
Burd,  Adams,  and  Macleod  have  each  published  a  case.     Karpinski's 


Bilateral  dislocation.    (After  Niehaus.) 


FRACTURES  OF  THE  UPPER  ESI)  OF  THE  FEMUR.        433 

case  was  very  typical.  A  well-developed  man,  twenty-one  years  old, 
had  sustained  a  dislocation  of  the  left  hi])  five  years  previously.  All 
movements  of  the  joint  in  walking  were  free,  but  in  addition  the  patient 
could  dislocate  the  head  of  the  femur  backward  into  the  outer  cavity 
of  the  ilium  with  a  loud  snap  by  placing  the  weight  of  the  body  on  the 
left  leg  and  rotating  the  body  to  the  left.  The  head  could  be  felt  distinctly. 
The  great  trochanter  stood  some  distance  above  the  Roser-Nelaton  line. 
By  simply  contracting  the  hip  muscles  he  could  reduce  the  dislocation 
without  further  aid.  As  Pitha  has  said  rightly,  voluntary  dislocation 
is  a  trick,  the  patients  learning  to  control  the  individual  muscles  favoring 
the  dislocation.  By  constant  practice  it  is  possible  to  learn  to  dislocate 
many  joints  voluntarily;  for  example,  Macleod's  case,  the  American 
athlete  Warren,  could  dislocate  and  reduce  almost  all  his  large  joints 
voluntarily.  A  secondary  dilatation  of  the  capsule  goes  hand  in  hand 
with  the  training  of  the  muscles;  that  is  the  only  thing  found  so  far  in 
autopsies.  A  congenital  anomaly  of  the  joint  or  a  congenital  defect  of 
the  joint-surfaces  can  be  excluded,  as  the  dislocation  does  not  occur 
involuntarily  as  it  does  in  habitual  dislocations.  Previous  trauma  is 
often  stated  as  the  cause.  Trauma,  however,  can  only  be  the  predis- 
posing cause  in  directing  the  attention  of  the  patient  to  the  joint.  Vol- 
untary dislocation  causes  no  harm,  and  therefore  does  not  require 
treatment. 

FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR. 

Anatomy  and  Physiology. — The  articular  head  of  the  femur  is  sepa- 
rated from  the  shaft  by  a  long  neck,  at  the  base  of  which  are  two 
trochanters,  muscular  tuberosities,  much  more  strongly  developed  than 
in  the  humerus.  The  neck  is  attached  to  the  shaft  at  an  angle,  so  that 
the  great  trochanter  represents  the  upper  end  of  the  shaft.  According 
to  an  earlier  view  generally  accepted,  the  angle  between  the  neck  and 
shaft  was  supposed  to  be  more  acute  in  women  than  in  men,  namely, 
more  of  a  right  angle.  This  is  not  the  case.  Sharpey's  recent  inves- 
tigations show  that  the  angle  is  the  same  in  adults  and  elderly  indi- 
viduals, men  and  women,  and  only  about  2  degrees  wider  in  children. 
It  is  usually  about  127  degrees,  varying  between  115  and  140  degrees. 
It  is  smaller  after  rhachitis. 

The  head  develops  from  a  separate  epiphysis,  the  line  of  which  corre- 
sponds to  the  articular  margin.  The  trochanters  each  have  a  separate 
primary  centre;  on  the  other  hand,  the  condyles  have  a  common  epiphysis 
the  line  of  which  still  exists  in  the  eighteenth  or  twentieth  year,  running 
in  front  above  the  trochlea,  at  the  sides  above  the  epicondyles,  and 
behind  along  the  linea  poplitea.  The  femur  has  to  bear  the  entire 
weight  of  the  body  in  the  upright  position.  The  power  of  resistance 
or  a  bone  is  naturally  decreased  considerably  by  any  inflexion  in  its  axis, 
and  this  is  the  case  in  the  femur  from  the  angular  deviation  of  the  neck. 
This  would  therefore  be  the  weakest  part  of  the  bone  if  nature  had  not 
fitted  it  for  its  burden  by  a  particular  construction.  The  neck,  in  addi- 
Vol.  III.— 28 


4:j4  INJURIES  OF  THE  HIP. 

tion  to  being  arched,  is  more  convex  on  its  posterior  surface  than  on  the 
anterior  and  longer;  further,  it  is  wedge-shaped,  the  sharp  edge  directed 
downward.  It  is  thicker  from  above  downward  than  from  before 
backward.  A  prominent  ridge  run-  from  its  inner  circumference  to  the 
great  trochanter.  The  compact  substance  is  strongest  where  the  greatest 
weight  is  carried.  That  portion  corresponding  to  the  inner  lower  part 
of  the  neck  is  called  Adams'  arch.  Further  strength  is  given  by  a 
compact  ridge  of  bone  projecting  at  the  level  of  the  lesser  trochanter 
toward  the  middle  line,  penetrating  \  inch  into  the  spongiosa  and  dis- 
appearing immediately  beneath  the  head  on  the  anterior  surface  of  the 
neck  | Bigelow's  septum,  Merkel's  Schenkelsporn,  calcar  femorale).  To 
a  certain  extent  it  supports  the  Lesser  trochanter;  from  it  the  spongiosa 
radiates  fan-shaped  toward  the  outer  and  especially  the  posterior  surface 
of  the  great  trochanter.  The  strength  of  the  neck  is  dependent  par- 
ticularly upon  the  structure  and  arrangement  of  the  spongiosa.  We 
are  indebted  to  Culmann  the  mathematician,  v.  Meyer  the  anatomist, 
and  the  surgeons  Packard,  J.  Wolff,  Heppner,  and  Riedinger  for  a  clear 
insight  into  this  wonderful  production  of  nature.  These  authors  have 
shown  that  in  its  construction  the  spongiosa  corresponds  to  the  statical 
lines  of  pressure  and  tension.  It  is  built  as  one  would  construct  a  bone 
mathematically  to  carry  weights.  In  detail  the  lamellae  can  be  separated 
into  distinct  systems,  especially  in  thin  sections,  the  Packard-Meyer 
1  i lie-—  running  through  the  neck  and  recurring  with  great  regularity. 
This  arrangement  of  the  spongiosa  is  only  interrupted  at  places  by  the 
nutrient  vessels  of  the  neck  dipping  down  into  the  bone.  The  head 
receives  its  blood-supply  in  youth  through  the  vessels  transmitted  through 
the  ligamentum  teres;  later  in  life  these  vessels  disappear  for  the  most 
part.  (Langer.  Senn.)  The  nutrition  of  the  head  is  then  supplied  by 
the  spongiosa  of  the  neck. 

According  to  P.  v.  Brans'  statistics,  the  frequency  of  fractures  of  the 
femur  is  represented  by  6  per  cent.,  of  which  a  fourth  part  applies  to 
the  neck,  the  fracture-  of  which  occur  chiefly  in  old  age.  Fractures  of 
the  upper  end  of  the  femur  include:  1  those  of  the  head.  (2)  of  the 
neck,    3    of  the  great  trochanter,    4    and  in  the  epiphyseal  line. 

Fracture  of  the  Head  of  the  Femur. — Dupuytren  states  that  com- 
pression-fracture of  the  head  not  infrequently  results  from  falling  upon 
the  feet  or  upon  the  great  trochanter,  and  that  it  is  apt  to  be  treated  as 
a  contusion  of  the  hip-joint.  Evidence  for  this  statement  has  never  been 
brought  forward,  nor  are  there  any  specimens  of  this  sort.  The  only 
authentic  case  of  fracture  of  the  head  is  reported  by  Riedel.  A  fifteen- 
■  >ld  boy  was  run  over  by  a  heavy  wagon.  There  was  an  actual 
shortening  of  2  inches  in  the  affected  limb;  it  was  flexed  and  rotated 
inward  a-  in  the  usual  iliac  dislocation.  On  passive  motion  the  elastic 
resistance  was  lacking,  however,  and  an  indistinct  crepitus  could,  be 
felt.  After  incising  at  the  point  of  injury  and  removing  the  great  tro- 
chanter the  head  and  neck  were  found  to  be  split  longitudinally.  Both 
fragments  lay  outside  of  the  joint-cavity,  the  upper  posterior  margin  of 
which  was  indented.     Riedel  conceived  that  the  head  was  first  forced 


FRACTURES  OF  I  ill    UPPER  END  OF  THE  FEMUR.        435 

againsl  the  posterior  margin  of  the  cavity;  at  the  moment  in  which  it 
rested  on  the  margin  that  it  was  struck  by  a  second  force  and  >plit  into 
two  pieces  upon  the  sharp  margin.  The  upper  outer  fragment  was 
removed  and  the  rest  of  the  head  returned  to  the  cavity.  Recovery 
followed  with  complete  ankylosis  of  the  joint  and  1  inch  shortening. 

Fracture  of  the  Neck  of  the  Femur.  — In  children  and  in  men  in 
the  prime  of  life  fracture  of  the  neck  is  rather  rare.  It  is  more  frequent 
after  the  fiftieth  year,  and  after  the  seventieth  year  constitutes  a  third 
of  the  fractures.  The  fact  that  its  frequency  increases  with  age  is 
easily  explained  by  the  changes  occurring  with  age  in  the  bone.  Jt  has 
been  seen  that  in  the  prime  of  life  on  account  of  the  peculiar  form  and 
anatomical  structure  of  the  neck  it  is  aide  to  carry  the  weight  of  the  body 
and  resisl  external  violence.  This  is  true  up  to  the  fiftieth  year;  then 
the  changes  gradually  take  place  which  affect  the  entire  skeleton,  namely, 
the  senile  osteoporosis,  an  eccentric  atrophy  of  the  bone.  The  cortex, 
especially  in  Adams'  arch,  becomes  thinner  and  thinner.  Many  of  the 
lamellae  of  the  spongiosa  are  absorbed  and  are  replaced  by  large  cavities 
filled  with  yellow  marrow.  The  calcar  femorale  disappears  largely;  the 
angle  between  the  neck  and  shaft  approaches  a  right  angle.  All  the 
conditions  which  formerly  gave  the  neck  its  power  of  resistance  are  lost, 
and  more  especially  in  women  than  in  men;  so  fracture  is  more  frequent  . 
in  the  former  than  in  the  latter.  Often  very  little  force  is  required  to  ^ 
break  the  neck  of  the  femur;  so  the  cause  is  frequently  stated  to  be  not 
only  a  fall  upon  the  feet,  the  knees,  the  buttock,  or  a  blow  against  the 
outer  part  of  the  hip,  but  even  a  misstep  or  stumbling,  accompanied  by 
a  forcible  effort  to  maintain  an  upright  position. 

The  neck  is  apt  to  break  in  one  of  two  places:  at  its  junction  with 
the  head  or  at  the  base,  its  attachment  to  the  trochanter.  The  fracture 
is  intracapsular  or  extracapsular  according,  in  its  relation  to  the  capsule, 
as  it  is  near  the  head  or  at  the  base.  The  so-called  mixed  fracture  is 
usually  intracapsular  in  front,  extracapsular  behind,  as  the  capsule  in 
the  latter  place  extends  only  to  about  the  middle  of  the  neck.  The 
experience  has  been  that  a  fall  upon  the  foot  or  knee,  namely,  force 
applied  in  the  long  axis  of  the  femur,  usually  causes  fractures  near  the 
head,  and  that  force  applied  on  the  outer  side  of  the  trochanter,  namely, 
in  the  long  axis  of  the  neck,  produces  fracture  near  the  trochanter. 
Further  information  is  given  by  numerous  experiments.  (Heppner, 
Streubel.  Riedinger,  Rodet,  Lardy,  Mermillod.)  Force  applied  in  a 
vertical  direction — that  is,  to  the  thigh  through  the  foot  or  knee — 
produced  oblique  fracture  of  the  neck  near  the  head  or  more  toward 
the  middle.  Applied  to  the  trochanter  from  the  side,  it  produced 
impacted  fracture  of  the  neck  at  its  base  or  impacted  fracture  of  the 
anatomical  neck  with  much  splintering.  From  before  backward,  it 
produced  transverse  intracapsular  fractures.  By  forcibly  rotating  the 
thigh,  Lardy  once  produced  incomplete  impacted  fracture. 

Fracture  also  results  from  muscular  action  exaggerating  the  physio- 
logical movements  of  the  hip-joint  or  from  lifting  heavy  weights,  which 
is    also    an    indirect    muscular    action,  the    muscles   transmitting  the 


436 


INJURIES  OF  THE  HIP. 


pressure  to  the  neck.  The  tear  fractures  of  the  neck  produced  by 
the  ligament  of  Bertin,  for  our  knowledge  of  which  we  are  indebted 
to  Linhart  and  Riedinger,  are  especially  interesting:  in  stumbling 
or  slipping  the  body  is  thrown  backward  quickly  to  check  the  fall; 
the  hyperextension  of  the  hip-joint  tightens  the  iliofemoral  ligament, 
and  the  latter  by  reason  of  its  greater  strength  tears  the  neck  from  its 
base.  The  fracture  is  always  purely  extracapsular;  the  fracture-line  in 
front  is  clean,  behind  jagged;  the  Y-ligament  remains  attached  to  the 
neck. 

Pathological  Anatomy. — The  occurrence  of  incomplete  fracture  of  the 
neck — infraction — has  been  known  for  a  long  while.  (Colles,  Adams.) 
Recently  Kdnig  has  again  called  attention  to  it.  It  is  almost  always 
purely  intracapsular;  in  only  2  instances  was  the  fracture-line  partly 
within  and  partly  without  the  joint.  Infraction  may  occur  above,  below, 
or  behind  in  the  neck  (Figs.  268  and  269),  the  cortex  on  the  other  side 


Fig.  268. 


Fig.  269. 


Lac  implete  fractures  of  the  neck.     (Konig.) 


being  more  or  less  intact;  sometimes  there  is  no  displacement;  in  other 
instances  the  head  is  bent  downward,  backward,  or  upward,  the  neck 
being  impacted  in  the  spongiosa  of  the  head.  This  inflexion  presupposes 
a  certain  amount  of  pliability  in  the  intact  cortex,  which  in  turn  is  due 
to  rarefaction  of  the  bone  caused  by  eccentric  atrophy.  (P.  v.  Brims.) 
Infraction  is  caused  by  diminished  violence,  either  by  the  weight  of  the 
body  alone  or  by  a  force  partially  spent  in  producing  other  injuries; 
so  fracture  of  the  great  trochanter  or  of  the  shaft  are  found  with  the 
infraction.  The  diagnosis  of  infraction  in  anatomical  specimens  is  to 
be  given  guardedly,  as  healed  complete  impacted  fractures  have  the 
same  appearance. 

Complete  fracture  of  the  neck  is  intracapsular,  extracapsular,  or 
mixed,  any  of  which  may  be  impacted.  The  relative  frequency  of 
intracapsular  and  extracapsular  fracture  has  been  a  matter  of  consider- 
able discussion;  Malgaigne  regards  the  former  as  more  frequent.  This 
is  apparently  not  so,  however;  according  to  Senn's  recent  statistics,  they 


FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR. 


■;:]- 


are  about  equally  frequent,  1  •">•'»  intracapsular  to  1~>7  extracapsular — but 
pure  extra-articular  fractures  are  a  great  rarity,  the  so-called  extracap- 
sular fractures  being  usually  mixed. 

Subperiosteal  fractures  occur  occasionally;  the  capsule  may  be  intact, 
but  usually  both  periosteum  and  capsule  are  torn  slightly. 

Intracapsular  fractures  are  more  frequently  oblique  than  transverse, 
and  occur  at  the  junction  of  the  head  and  neck,  the  thinnest  pail  of  the 
neck  (Fig.  270,  fractura  subcapitalis,  Kocher).  Sometimes  part  of  the 
head  is  broken  off.  The  fracture  surfaces  are  usually  serrated,  rarely 
splintered;  they  may  be  free  or  impacted;  if  free  and  the  capsule  is 
intact,  there  is  no  displacement;  if  the  capsule  is  not  intact,  the  trochan- 
teric part  of  the  neck  is  lifted  by  the  elastic  retraction  of  the  muscles 
inserted  on  the  great  trochanter.  The  trochanter  thus  approaches  the 
crest  of  the  ilium,  and  is  checked  either  by  the  resistance  of  the  uninjured 


Fig.  270. 


Fig.  271. 


Impacted  subcapital  fractures. 

part  of  the  capsule  or  by  the  abutment  of  the  lesser  trochanter  against 
the  inner  fragment.  If  impaction  occurs,  the  lower  posterior  portion  of 
the  cortex  of  the  outer  fragment  is  wedged  into  the  spongiosa  of  the  head ; 
there  is  not  necessarily  any  great  displacement.  (Fig.  271.)  Usually, 
however,  the  head  is  rotated  inward  and  inclined  so  far  backward  that 
it  touches  the  posterior  intertrochanteric  line.  (Fig.  272.)  The  serra- 
tions in  the  anterior  part  of  the  fracture-line  then  interlock.  The  lower 
part  of  the  neck  is  occasionally  forced  into  the  spongiosa  of  the  head 
so  that  the  upper  part  overrides  the  joint  surface.  (Fig.  273.)  In 
childhood  and  youth  intracapsular  fracture  occasionally  occurs  as  a 
separation  of  the  epiphysis  between  the  head  and  neck. 

Extracapsular  fractures  may  run  in  various  directions:  along  the 
intertrochanteric  line,  ending  near  the  lesser  trochanter  or  directly 
beneath  it  (Fig.  274,  fractura  intertrochanterica,  Kocher);  or  the  line 
may  run  obliquely  through  the  trochanters  (fractura  pertrochanterica, 


438 


INJURIES  OF  THE  HIP. 


Kocher).     The  above  forms  are  very  frequently  combined  to  produce 
Kocher's  Y,  I,  or  L  fracture    "  ZertriimmerUngsbruch,  Pels-Leusden "). 

In  this  case,  in  addition  to  the  fracture  of  the  neck,  a  second  fracture-line 


Fig.  272 


Fig.  273. 


Impacted  fracture?  of  the  neck.     'After  I 


Comminuted  fracture  of  the 
upper  end  of  the  femur. 


runs  horizontally  through  the  great  trochanter  above  the  lesser  tro- 
chanter; or  the  great  trochanter  is  broken  into  several  pieces.  I  Fig.  27"). ) 
Very  rarely  the  splintering  involves  the  neck.     The  great  trochanter  is 


1  i  ,.  276. 


Impacted  extracapsular  fractures.     'After  L   - 


most  frequently  broken  off  in  the  form  of  a  long  quadrilateral  in  the 
portion  bounded  by  the  posterior  intertrochanteric  line.  This  quadri- 
lateral is  longer  if  the  lesser  trochanter  is  involved,  which,  according  to 
Riedinger,  is  the  more  frequent  occurrence.    The  lesser  trochanter  may 


FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR. 


439 


be  broken  off  separately.     (Linhart.)    The  variations  in  these  fractures 
are  numerous;  Beimel  recently  classified  thirteen  types. 

The  large  majority  of  cases  of  extracapsular  fracture  are  impacted, 
the  impaction  being  complete  or  incomplete.  In  the  less  frequent 
incomplete  form  one  side,  usually  the  hack  or  lower  part  of  the  neck, 
is  impacted  in  the  trochanter.  (Fig.  270.)  If  complete,  the  epiphyseal 
fragmenl  and  neck  are  driven  deeply  into  the  spongiosa  of  the  trochan- 
teric portion.  (Fig.  277.)  The  pointed  fragment  of  Adams'  arch  is 
also  forced  deeply  into  the  crushed  hone.  (Fig.  278.)  The  great 
trochanter  is  twisted  backward,  approaches  the  head,  and  the  shaft  of 
the  femur  is  rotated  outward.  In  exceptional  cases  the  shaft  is  rotated 
inward,  so  that  the  neck  is  shorter  in  front  than  behind.  The  angle 
between  the  shaft  and  neck  usually  approaches  a  right  angle,  although 
it  may  be  more  obtuse.     In  the  absence  of  impaction  displacement  is 


Fig.  277. 


Fig.  278. 


Impacted  extracapsular  fracture  of  the  neck.     (After  Lessen.) 

always  marked.  As  the  capsule  does  not  hinder  the  elastic  retraction 
of  the  muscles  inserted  into  the  lower  fragment  from  coming  into  full 
play,  the  shaft  of  the  femur  is  drawn  up  above  and  behind  the  fragment 
of  the  neck  by  the  action  of  the  gluteals  and  the  rectus  femoris  in  front 
and  the  biceps,  semitendinosus  and  semimembranosus  behind.  At  the 
same  time  the  lower  fragment  (the  shaft)  is  apt  to  be  rotated  outward 
by  the  weight  of  the  limb,  as  will  be  explained  later. 

Symptoms. — It  is  impossible  to  locate  fractures  of  the  neck  accurately 
on  account  of  the  shortness  of  the  fragment  and  its  deep  situation 
beneath  the  firm  tissues.  In  practice  it  is  most  important  to  determine 
whether  the  fracture  is  free  or  impacted. 

Subjective  Symptoms. — Pain  is  always  present,  usually  slight  if  the 
parts  are  quiet,  but  very  intense  during  active  or  passive  movements  of 
the  limb.  If  the  fracture  is  near  the  head,  the  pain  is  more  in  the 
inguinal  region;  if  at  the  base,  it  is  more  at  the  outer  and  upper  part 


440 


INJURIES  OF  THE  HIP. 


of  the  hip,  and  is  increased  by  attempts  at  flexion  or  extension.  The 
loss  of  function  depends  on  the  nature  of  the  displacement.  If  unim- 
pacted,  motion  is  lost,  or  at  least  the  limb  cannot  be  lifted  in  the  recum- 
bent position  if  extended.  If  intracapsular,  sometimes  the  patient  can 
flex  the  thigh  and  knee  and  draw  the  heel  up  toward  the  thigh  without 
fifting  it.  If  the  fracture  is  extracapsular,  this  is  usually  so  painful  that 
the  patient  prefers  not  to  attempt  it.     If  the  fracture  is  impacted,  the 

loss  of  motion  may  be  slight,  the  patient 
may  be  able  to  lift  the  limb,  to  stand,  upon 
it,  or  even  to  walk  a  few  steps.  The  latter 
is  particularly  true  of  impacted  extracap- 
sular fractures. 

Objective  Symptoms.  —  On  inspection 
the  changed  form  of  the  hip  due  to  the 
swelling  is  noticeable  (Fig.  279) ;  the  inguinal 
fold  is  obliterated  according  to  the  site  of 
the  fracture.  An  angular  deviation  of  the 
neck  can  be  felt  on  deep  pressure  in 
Scarpa's  triangle.  The  fold  of  the  but- 
tock is  less  pronounced  than  on  other 
side.  Usually  swelling  is  more  marked 
in  fracture  at  the  base  of  the  neck,  corre- 
sponding to  the  greater  loss  of  substance. 
If  there  is  much  extravasation  of  blood, 
ecchymosis  appears  sooner  and  more  con- 
stantly in  proportion  to  the  proximity  of 
the  fracture  to  the  shaft;  if  the  fracture  is 
extracapsular,  it  appears  chiefly  about  the 
trochanter,  but  may  extend  over  the  entire 
thigh;  if  intracapsular,  it  appears  in  a  few 
days  in  the  groin  below  Poupart's  ligament. 
Outward  Rotation. — The  lower  extremity 
is  normally  rotated  outward  to  a  slight  ex- 
tent on  account  of  the  forward  direction  of 
the  neck.  This  is  increased :  in  the  absence 
of  impaction  by  the  weight  of  the  limb  ; 
with  impaction,  from  the  fact  that  it  is 
chiefly  the  back  part  of  the  fracture  surfaces 
which  are  impacted,  the  shaft  being  thus 
rotated  outward.  A  line  drawn  through  the  axis  of  the  lower  extremity 
passes  through  the  anterior-superior  spine  and  the  tip  of  the  great  toe;  the 
part  of  the  limb  lying  to  the  outer  side  of  this  axis  is  much  heavier  than 
the  inner  part.  If  the  normal  support  of  the  limb,  the  neck,  is  broken,  the 
thigh  naturally  rotates  outward.  The  degree  of  rotation  in  impacted 
fracture  depends  upon  the  degree  of  impaction  of  the  posterior  fracture 
surfaces.  In  the  absence  of  impaction  the  limb  usually  rests  upon  its 
outer  surface,  flexed  slightly  at  the  knee  and  hip  with  the  heel  touching 
the  space  between  the  internal  malleolus  and  the  tendo  Achillis  of  the 


Fracture  of  the  neck. 


FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR. 


441 


other  leg.  The  outward  rotation  is  easily  corrected.  With  impaction 
it  is  more  difficult  —in  fact,  it  should  not  be  attempted.    Very  rarely  the 

linil)  is  rotated  inward  if  the  anterior  wall  of  the  neck  is  driven  into  the 
spongiosa  of  the  trochanter  so  that  the  trochanteric  fragment  projects 
in  front  of  the  neck.  The  inward  rotation  is  then  overcome  only  by 
forcibly  breaking  up  the  impaction.  Sometimes  it  may  happen  that  the 
limb  is  rotated  inward  by  the  patient  or  bystanders,  and  can  then 
naturally  be  rotated  outward  easily. 

Shortening. — Next  to  outward  rotation,  shortening  is  the  most 
important  symptom  of  fracture  of  the  neck.  It  depends  upon  the 
lessening  of  the  angle  between  the  neck  and  shaft,  which  approaches 
more  to  a  right  angle,  upon  impaction  of  the  fragments,  or  their  displace- 
ment longitudinally.  The  shortening  with  impaction  is  rarely  more 
than  an  inch.  In  intracapsular  fractures  the  intact  portion  of  the  capsule 
prevents  longitudinal  displacement,  or  the  lesser  trochanter  impinges 
against  the  upper  fragment;  the  shortening  is  then  moderate,  not  over 


Bryant's  method  of  measurement. 


\\  inches.  Later,  if  the  capsule  yields,  the  shortening  may  increase. 
(Bardeleben.)  If  the  lower  fragment  rises  above  the  neck,  the  short- 
ening may  be  from  3  to  4  inches.  This  does  not  take  place  gradually, 
but  often  suddenly  if  an  impaction  gives  way  and  muscular  action  comes 
into  play. 

Measurement  is  not  always  easy.  Wight's  method  is  the  best;  the 
anterior-superior  spines  should  be  horizontal,  the  limbs  parallel  to,  or 
equally  abducted  from,  the  middle  line  of  the  body,  and  then  the  fol- 
lowing measurements  made  on  both  sides:  1,  the  distance  from  the 
anterior  superior  spine  to  the  most  prominent  point  on  the  internal 
malleolus;  2,  to  the  most  prominent  point  on  the  external  malleolus; 
3,  the  distance  from  the  tip  of  the  great  trochanter  to  the  most  promi- 
nent point  on  the  external  malleolus;  4,  the  distance  from  the  cleft  of 
the  knee-joint  to  the  tip  of  the  internal  malleolus.  Bryant's  method 
consists  in  dropping  a  perpendicular  from  the  anterior-superior  spine 
and  measuring  the  distance  of  the  tip  of  the  trochanter  from  this  line, 
compared  with  the  other  side.  (Fig.  2S0.)  Very  rarely  there  is  an 
actual  lengthening  of  the  limb  if  the  fragment  of  the  neck  is  displaced 
upward.    To  this  the  term  coxa  valga  is  applied.    (Thiem.) 


442  INJURIES  OF  THE  HIP. 

Muscular  Relaxation. — Simultaneous  with  the  shortening  the  muscles 
running  from  the  pelvis  to  the  thigh,  especially  the  tensor  fascia?  latse 
and  the  gluteals,  are  relaxed.  This  produces  a  pathognomonic  symp- 
tom: on  the  sound  limb  in  the  space  between  the  trochanter  and  the 
crest  of  the  ilium  can  be  felt  a  resistance  produced  by  the  tension  of  the 
tensor  fascia?  lata?  and  gluteus  medius;  in  fracture  of  the  neck  there  is 
a  deep  depression  here.  (Allis,  Bezzi.)  In  non-impacted  fractures 
crepitus  is  occasionally  obtainable  on  palpation;  false  motion  is  con- 
stant. Crepitus  may  be  elicited  by  rotating  the  thigh  or  pressing  on 
the  back  of  the  trochanter.  If  in  doubt  as  to  the  existence  of  im- 
paction, one  should  never  attempt  to  elicit  crepitus  by  force,  as 
impaction  aids  recovery.  Crepitus  is  usually  obtainable  in  unimpacted 
extracapsular  fractures. 

False  Motion. — False  motion  is  usually  demonstrable  by  rotating  the 
thigh  with  the  hand  on  the  trochanter.  The  latter  rotates  about  a 
shorter  radius  than  on  the  sound  side.  In  impacted  fracture  this  is  the 
natural  result  of  the  shortening  of  the  neck;  in  unimpacted  fracture  the 
symptom  is  more  pronounced  the  nearer  the  fracture  to  the  trochanter. 
In  pure  extracapsular  fracture  the  trochanter  rotates  about  the  long  axis 
of  the  thigh;  if  there  is  impaction  or  splintering,  the  trochanter  is  widened. 
It  is  always  displaced  upward  and  backward  in  proportion  to  the  amount 
of  shortening  and  outward  rotation.  Marked  upward  displacement  of 
the  trochanter  presupposes  fracture  of  the  lesser  trochanter.  If  the 
extremity  is  rotated  inward,  these  cases  closely  resemble  iliac  dislocation. 
In  one  instance  Malgaigne  discovered  his  error  only  on  eliciting  crepitus 
while  attempting  reduction.  In  impacted  intracapsular  fracture  the 
trochanter  is  less  prominent;  also  if  both  fragments  are  displaced  upon 
each  other. 

Diagnosis. — If  all  the  above  symptoms  are  marked,  the  diagnosis  is 
not  difficult,  and  one  will  easily  be  able  to  determine  whether  the  fracture 
lies  near  the  head  or  near  the  trochanter,  whether  free  or  impacted. 
The  hip-joint  may  be  greatly  swollen,  however,  the  shortening  and 
outward  rotation  slight,  and  the  functional  loss  partial.  Even  then  the 
fracture  can  be  determined  with  approximate  certainty  if  the  examina- 
tion is  systematic  and  the  symptoms  taken  up  in  order  as  mentioned. 
Usually  it  is  not  advisable  to  use  an  anaesthetic,  as  an  impaction  is  easily 
loosened  and  the  firm  resistance  of  the  impaction  against  every  move- 
ment is  the  best  aid  in  the  diagnosis.  For  impaction  speak  further:  slight 
shortening  and  outward  rotation,  intense  pain  at  point  of  fracture,  dis- 
tinct broadening  of  the  trochanter,  considerable  swelling  and  ecchymosis 
around  it,  the  ability  to  lift  the  extended  limb,  and  the  history,  most 
of  the  fractures  due  to  a  blow  upon  the  trochanter  being  impacted  and 
extracapsular. 

Careful  study  of  the  symptoms,  namely,  the  entire  symptom-complex, 
will  usually  make  it  possible  to  determine  the  site  of  the  fracture.  The 
differential  symptoms  will  be  given  later  in  tables  comparing  the  diag- 
nostic points  of  injuries  of  the  hip-joint  and  pelvis,  with  special  reference 
to  the  exclusion  of  unilateral  fractures  of  the  pelvis,  forward  dislocation 


FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR. 


443 


of  the  thigh,  fracture  with  inward  rotation,  and  iliac  dislocation.  The 
differential  diagnosis  from  contusion  of  the  hip-joint  is  often  difficult; 
then'  may  be  loss  of  function;  elevation  of  the  pelvis  on  the  affected  side 
may  simulate  shortening;  the  limb  may  be  slightly  Hexed  and  rotated 
outward.  If  the  examination  is  hindered  by  severe  pain,  doubt  may 
well  be  entertained  unless  Hodgson's  suggestion  is  remembered:  "If  as 
the  result  of  a  fall  upon  the  hip  an  elderly  person  is  unable  to  use  the 
affected  limb,  it  is  highly  probable  that  there  is  a  fracture  of  the  neck, 
the  more  so  if  no  especially  great  violence  was  applied  in  the  fall  such  as 
would  be  necessary  to  produce  a  contusion  of  sufficient  severity  to  render 
the  thigh  useless."  Furthermore,  in  contusion  all  functional  disturb- 
ance and  suffering  gradually  decrease,  whereas  in  fracture  they  increase. 
In  fracture  of  the  neck  one  should  never  fail  to  examine  for  simul- 
taneous fracture  of  the  shaft.     In  incomplete  fracture  of  the  neck,  the 


P^ig.  281. 


Fig.  282. 


Subcapital  fracture  with  bony  union. 
(Senn.) 


Complete  absence  of  any  union  between  the  head  and 
neck  following  subcapital  fracture.     (Senn.) 


limb  is  in  its  normal  position  or  rotated  outward  slightly  and  somewhat 
shortened.  It  will  be  almost  impossible  to  establish  the  diagnosis  posi- 
tively. Usually  the  condition  is  regarded  as  a  contusion  of  the  hip-joint. 
It  is  self-understood  that  at  the  present  time  the  x-ray  gives  the  best 
information  in  regard  to  the  injury  present. 

Prognosis. — Fracture  of  the  neck  is  by  no  means  a  harmless  injury. 
It  may  lead — although  rarely — to  acute  suppuration  of  the  joint,  which 
in  view  of  the  age  of  the  patient  is  not  to  be  underestimated.  Sudden 
death  may  occur  soon  after  the  injury  from  fat-embolism,  the  marrow 
at  the  point  of  fracture  being  forced  into  the  open  lumen  of  an  adjacent 
vessel.  (Konig.)  Protracted  recumbency  may  increase  old  chronic  affec- 
tions of  the  lungs,  especially  in  the  aged,  with  hypostatic  pneumonia 
and  death,  or  may  produce  bedsores  resulting  fatally. 


444 


INJURIES  OF  THE  HIP. 


Fig.  283. 


In  intracapsular  fracture  bony  union  is  rare.  Senn  was  only  able  to 
collect  .54  authentic  cases  of  this  sort.  With  bony  union  the  neck  is 
found  almost  without  exception  to  have  disappeared  entirely,  the  head 
being  attached  immediately  to  the  trochanter.  (Fig.  281. )  Very  little 
callus  is  found  on  the  surface  of  the  neck.  The  larger  proportion  of  the 
cases  of  bony  union  are  incomplete  fractures  and  those  with  impaction. 
Exact  coaptation  is  indispensable  for  the  union  of  unimpacted  frac- 
tures. 

The  majority  of  intracapsular  fractures  heal  with  pseudoarthrosis,  the 
atrophied  fracture  surfaces  being  united  by  fibrous  tissue  of  varying 
firmness.  Sometimes  the  later  use  of  the  limb  produces  a  sort  of  arthro- 
dial  joint  between  the  fragments.  (Fig.  282.)  Occasionally  the  head 
is  entirely  absorbed;  the  neck  becomes  smoothed  off  and  forms  a  new 

articular  surface.  The  strength  of  the  neck 
is  naturally  diminished  by  the  formation  of 
a  false  joint  so  that  the  patients  require 
the  aid  of  crutches  or  a  cane.  Sometimes 
the  lower  fragment  finds  sufficient  support 
against  the  hypertrophied  outer  arm  of  the 
Y-ligament  and  the  tendon  of  the  obturator 
externus  to  bear  the  weight  of  the  body. 

Non-union  in  intracapsular  fracture  is 
referable  to  various  circumstances.  Often 
it  is  impossible  to  secure  the  immobiliza- 
tion of  both  fragments  essential  for  the 
formation  of  callus  on  account  of  the  inac- 
cessibility of  the  fracture.  Further,  the 
fractured  head  is  subjected  to  conditions 
very  unfavorable  to  its  nutrition.  Senile 
atrophy  impairs  the  blood-supply  of  the 
neck;  in  addition  the  vessels  are  damaged 
by  the  fracture;  those  running  through  the 
ligainentum  teres  of  the  head  are  insig- 
nificant. The  arteria  nutritia  colli  entering 
the  middle  of  the  neck  is  "cut  out"  by  a  fracture  near  the  head.  The 
small  vessels  running  into  the  neck  from  the  inverted  fold  of  the  capsule 
are  usually  torn,  and  so  the  blood-supply  of  the  head  is  entirely  cut  off. 
There  is  also  an  absence  of  any  real  periosteum  at  this  point.  These  are 
certainly  sufficient  reasons  for  the  lack  of  bone  production.  Probably 
the  atrophy  of  the  fracture  surfaces  and  the  disappearance  of  bony 
substance  are  due  to  the  malnutrition  of  the  tissues. 

In  extracapsular  fracture  the  conditions  are  quite  different ;  the  fracture 
surfaces  are  usually  held  in  apposition  by  impaction.  Even  if  the 
fragments  are  displaced  upon  each  other,  the  formation  of  callus  is  not 
often  compromised — in  fact,  the  callus  may  be  so  exuberant  as  to  limit 
the  movements  of  the  hip-joint.  The  usual  ring-shaped  exostosis 
following  impacted  fracture  is  shown  in  Fig.  283.  Complete  union 
requires  some  time — two  to  six  months.     During  this  time,  however,  the 


Excessive  callus  formation  following 
extracapsular  fracture.  'Lossen.) 


X 

w 
< 


FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR.        445 

spongiosa  is  often  completely  restored,  so  thai  the  lamelhe  conform  fully 
to  the  demands  made  by  tension  and  pressure.     (J.  Wolff.) 

The  earning-effieiency  of  the  patient  is  not  restored,  however,  when 
union  is  complete.  Some  of  the  patients  remain  incapacitated  on 
account  of  general  atrophy  and  shortening  of  the  limb;  others  on 
account  of  a  pseudarthrosis  or  stiffness  and  sensitiveness  of  the  hip  or 
knee-joint;  the  majority  on  account  of  the  high-grade  shortening. 
Accordingto  Haenel.of  19  cases  only  2  recovered  fully  (=  12  per  cent.); 
13  were  permanently  injured  (  =  77  per  cent.);  the  average  time  of 
complete  disability  was  eight  months. 

Arthritis  deformans  does  not  develop  so  frequently  after  fracture  of 
the  neck  as  was  formerly  supposed,  (v.  Yolkmann,  P.  v.  Brims.  |  Among 
a  large  number  of  hip-joints  examined  at  autopsy  by  Arbuthnot  Lane 
there  were  many  cases  of  fracture  of  the  neck;  in  three  of  these — one 
intra-  and  two  extracapsular — a  complete  nearthrosis  had  formed  close 
under  the  anterior  superior  spine  between  the  ilium  and  an  excessive 
growth  of  callus  from  the  shaft  of  the  femur. 

Treatment. — There  are  two  important  things  to  be  effected  in  the 
treatment  of  fracture  of  the  neck,  the  general  care  of  the  patient  and 
union  of  the  bones  in  proper  position.  Decubitus  and  hypostatic  pneu- 
monia are  to  be  prevented  if  possible.  The  patient  should  be  laid  upon  a 
v.  Volkmann-Hamilton  suspension-frame,  or  a  Messner  adjustable  bed, 
or  upon  a  good  horsehair  mattress.  Thin  and  weak  patients  should  be 
supplied  immediately  with  a  water-cushion,  and  great  cleanliness 
enforced,  especially  after  defecation.  The  patient  should  not  be  kept 
horizontal  during  the  entire  period  in  bed,  but  be  allowed  to  sit  up 
partially  as  early  as  possible.  Naturally  the  best  treatment  would  be  to 
do  away  with  the  recumbent  position.     This  will  be  returned  to  later. 

Reduction  will  be  required  only  for  unimpacted  fractures.  The  foot 
is  grasped  at  the  heel  with  one  hand  and  on  the  dorsum  with  the  other, 
and  by  gentle  traction  and  inward  rotation  the  limb  restored  to  its 
normal  position.  If  impaction  is  even  suspected,  it  is  not  justifiable  to 
attempt  forcible  reduction  on  account  of  the  loss  to  the  patient  in  loosen- 
ing an  impaction.  If  there  is  impaction  with  slight  shortening  and 
outward  rotation,  the  limb  is  simply  laid  between  sand-bags  and  left 
alone.  If  there  is  marked  displacement  the  surgeon  has  to  consider: 
immobilization  in  Bonnet's  woven-wire  splint  or  upon  a  double  inclined 
plane,  or  in  a  circular  plaster  splint  enclosing  the  limb,  hip,  pelvis,  and 
upper  third  of  the  sound  thigh.  These  immobilization  apparatus  are 
usually  only  temporary;  the  plaster  splint  also  only  for  transportation. 
For  treatment  in  the  recumbent  position  one  should  use  v.  Yolkmann 's 
adhesive  plaster  extension  splint. 

v.Volkmann's  Adhesive  Plaster  Extension  Splixt. — Two  strips  of 
adhesive  plaster  [mole-skin  plaster]  2h  to  3 \  inches  wide  are  applied  on  the 
sides  of  the  extremity  from  the  highest  possible  point  on  the  thigh  to  about 
4  inches  above  the  malleoli,  and  bound  on  with  a  flannel  roll.  Below  the 
ankle  the  strips  diverge  to  a  stirrup  plate  (spreader)  about  1  inch  below 
the  sole  of  the  foot.     This  plate  prevents  the  strips  from  pressing  against 


446 


INJURIES  OF  THE  HIP. 


the  malleoli  and  has  attached  to  it  the  traction  cord.  The  foot  is  ban- 
daged to  a  T-piece  well  padded  and  cut  out  at  the  heel.  In  a  few  hours, 
after  the  adhesive  plaster  has  become  adherent,  the  slide  is  placed  under 
the  foot  and  the  weight  attached.  The  weight  should  be  heavy  to  be 
effectual;  for  well-developed  patients  20  to  30  pounds,  or  even  forty, 
and  for  weaker  patients  10  to  20  pounds.  If  the  traction  is  right,  the 
pelvis  is  drawn  down  on  the  affected  side  so  that  the  extended  limb 
appears  1  to  H  inches  longer  than  the  other.  Counterextension  is  made 
either  by  elevating  the  foot  of  the  bed,  by  passing  a  rubber  band  around 
the  other  hip,  or  by  placing  a  foot-piece  against  the  other  foot.  By 
means  of  appropriately  placed  strips  of  adhesive  plaster  Bardenheuer 
always  adds  transverse  and  rotary  traction;  with  v.  Volkmann's  T-piece 
the  author  thinks  this  is  unnecessary. 

Fig.  284. 


Buck's  extension  with  a  v.  Volkmann  sliding  rest.     (Stimson.) 


By  this  method  the  average  time  of  recovery  is  eight  weeks.  In 
v.  Volkmann's  experience  the  shortening  is  slight.  The  extension  splint 
makes  it  possible  for  the  patient  to  sit  up  in  eight  to  fourteen  days. 
According  to  Morisani,  the  shortening  due  to  the  diminution  of  the 
angle  between  the  shaft  and  neck  can  be  prevented  by  abduction. 

The  Beely  plaster  suspension  splint  allows  the  patient  to  be  shifted 
about  more  in  bed.  The  splint  extends  from  the  groin  to  the  base  of 
the  toes  (Fig.  285),  the  rings  being  attached  at  the  outer  side  of  the 
middle  line  in  front  in  order  to  maintain  inward  rotation.  There  are 
a  number  of  other  extension  apparatus  proposed:  Bruns'  modification 
of  Dumreicher's  sliding  apparatus,  and  the  apparatus  of  Hennequin, 


FRACTURES  OF  THE  UPPER  END  <>F  THE  FEMUR. 


447 


Tillaux,  and  others,  but  they  arc  all  more  complicated  than  v.Yolkmann's 

or  Beely's. 

In..  285. 


Beely's  plaster-of -Paris  strip  splint  with  suspension  rings. 


The  extension  method  as  described  above  is  especially  suitable  for 
extracapsular  fracture.  The  traction  is  continued  for  three  to  four  weeks, 
and  then  a  plaster  splint  is  applied  and  the  patient  allowed  to  go  about 

Fig.  286. 


Hodgkin's  suspended  splint.      (.Stimson.) 


on  crutches.  The  method  is  hardly  indicated  for  intracapsular  fracture 
in  the  aged,  as  long  experience  has  taught  that  bony  union  does  not 
take  place  unless  there  is  impaction.    If  there  is  impaction,  bony  union 


448  INJURIES  OF  THE  HIP. 

is  good,  and  one  may  employ  the  ambulant  treatment  with  advantage 
as  described  later  under  Fractures  of  the  Shaft.  With  such  a  portable 
splint,  accurately  applied  to  prevent  loosening  of  the  impaction,  the 
patient  can  be  up  and  about  in  a  short  time. 

The  author  does  not  believe  that  it  is  advisable  to  torture  old  people 
for  weeks  with  an  extension  or  portable  splint  in  the  absence  of  any 
prospect  of  bony  union.  For  such  cases  two  methods  can  be  used: 
ambulant  treatment  with  massage,  or  excision  of  the  fragment  of  the 
head.  The  former,  recently  recommended  by  French  authors,  aims  to 
favor  the  production  of  a  pseudarthrosis  and  prevent  muscular  atrophy. 
The  muscles  of  the  entire  extremity  are  stroked  and  kneaded,  especially 
about  the  hip;  passive  motion  is  begun  as  soon  as  the  pain  permits, 
later  active  motion,  the  patient  being  encouraged  to  move  the  limb  and 
to  walk  as  soon  as  possible.  The  treatment  is  indicated  especially  for 
weak,  poorly  nourished  "  catarrhal "  patients.  The  results  are  fairly 
good. 

If  dealing  with  fairly  healthy  individuals,  immediate  operation  may 
be  proposed.  The  fragment  of  the  head  may  be  excised,  a  simple  opera- 
tion which  has  repeatedly  given  good  results.  Recently  attempts  have 
been  made  to  preserve  the  head  by  screwing  or  nailing  the  fragment. 
Langenbeck  fastened  the  fragments  with  screws  or  ivory  pegs,  an  attempt 
made  later  by  Konig  and  Trendelenburg.  Schede  has  recently  reported 
the  good  results  of  operation.  Senn,  in  order  to  avoid  operation,  pro- 
posed to  apply  a  splint  made  of  plaster  roll  bandages  while  the  patient 
stands  upon  a  stool  and  the  normal  position  of  the  limb  is  maintained 
by  traction  upon  the  foot.  A  pad  is  placed  over  the  great  trochanter  to 
exert  pressure  in  the  direction  of  the  neck  and  held  by  a  screw  arrange- 
ment; it  is  inspected  daily  and  removed  from  time  to  time  and  the  skin 
bathed  with  alcohol  to  prevent  pressure-sores.  The  head  has  been 
removed  recently  with  good  results  in  old  troublesome  fractures  of  the 
neck  with  pseudarthrosis.  (Fock,  Konig,  Hoffa.)  In  one  instance 
Loretta  freshened  up  the  fragments  with  a  raspatory  nineteen  months 
after  the  injury  and  obtained  union  in  four  weeks. 

Fracture  of  the  Great  Trochanter. — Separation  of  the  great  trochan- 
ter in  the  epiphyseal  line  or  fracture  later  in  life  at  the  corresponding  point, 
unaccompanied  by  fracture  of  the  neck,  is  a  very  rare  injury.  Recently 
Morris  was  only  able  to  collect  0  authentic  cases;  in  all  of  them  the 
cause  was  direct  violence  upon  the  trochanter,  usually  a  fall  or  blow. 
The  amount  of  displacement  varied  according  to  the  condition  of  the 
fibrous  and  tendinous  covering  of  the  trochanter,  the  fragments  remaining 
in  contact  if  the  coverings  were  only  partially  torn. 

Symptoms. — The  symptoms  were  those  of  severe  contusion,  fracture 
being  suspected  only  from  pain  localized  at  the  trochanter  and  increased 
by  pressure.  If  the  coverings  and  muscular  attachments  were  torn  from 
the  femur,  the  fragment  was  always  drawn  upward  and  backward — 
even  as  much  as  2\  inches — by  the  gluteus  medius  and  minimus.  In 
the  absence  of  much  swelling,  flattening  was  noticeable  at  the  site  of 
the   trochanter.      Palpation   of   the   fragments   is   often   impossible  on 


FRACTURES  OF  THE  UPPER  END  OF  THE  FEMUR.         449 

account  of  the  tension  of  the  surrounding  soft  parts  or  the  swelling; 
on  the  other  hand,  crepitus  may  be  elicited  by  flexing,  abducting, 
and  rotating  the  limb  outward  and  pressing  the  fragments  together. 
On  account  of  the  pain  the  limb  is  usually  held  slightly  flexed  and 
rotated  inward.  Motion  is  possible  in  all  directions.  Union  is  usually 
by  the  formation  of  a  false  joint.  Bony  union  is  only  possible  if  the 
fragments  are  held  together  by  the  periosteum  and  fibrous  covering. 

Treatment. — The  treatment  consists  in  immobilizing  the  limb  in 
abduction,  outward  rotation,  and  slight  flexion  at  the  knee  and  hip. 

Fracture  in  the  Epiphyseal  Lines.— Traumatic  Separation  of  the  Epi- 
physis of  the  Head. — Traumatic  separation  of  the  epiphysis  of  the  head 
has  recently  been  made  known  by  the  works  of  Tubby,  Whitmann, 
Sprengel,  and  especially  by  J.  Poland,  who  cites  20  cases.  The  author 
has  seen  and  operated  upon  4  cases.  Gerstle's  statistics  give  40 
authentic  cases  up  to  the  present  time. 

Separation  of  the  epiphysis  may  occur  at  birth  from  strong  traction 
on  the  femur,  but  is  most  frequent  between  the  tenth  and  fifteenth  year, 
when  the  ossified  head  is  more  resistant  than  the  epiphyseal  line,  so 
that  direct  violence  affects  the  latter  as  the  weakest  part  of  the  neck. 
Ossification  is  usually  complete  at  the  twenty-second  year.  The  cause 
is  commonly  indirect  violence,  a  blow  upon  the  hip,  or  by  falling  upon  the 
feet  or  jumping  with  excessive  outward  or  inward  rotation  of  the  limb. 
The  pathological  findings  vary;  there  may  be  a  pure  separation  of  the 
epiphysis,  so  that  the  head  can  be  removed  from  the  joint,  or  the  line 
of  fracture  may  extend  through  the  epiphyseal  line  into  the  neck. 

Symptoms. — The  picture  is  usually  that  of  a  subcapital  fracture  of 
the  neck,  the  characteristic  symptoms  being  soft  cartilaginous  crepitus, 
shortening  even  to  1  or  lh  inches,  and  generally  marked  outward  rota- 
tion. Active  motion  is  often  unimpaired  so  that  at  the  outset  the  patient 
may  be  able  to  walk. 

Diagnosis. — The  diagnosis  between  fracture  of  the  epiphysis  and  of 
the  neck  is  often  difficult,  but  is  facilitated  by  the  .v-ray.  Without  the 
latter  the  only  positive  evidence  is  to  be  obtained  by  operation. 

Prognosis. — The  prognosis  is  favorable  if  appropriate  treatment  is 
begun  at  the  outset,  otherwise  there  are  usually  shortening  and  outward 
rotation.  The  femur  is  displaced  upward  on  the  head  so  that  the  angle 
between  the  neck  and  shaft  is  considerably  diminished,  giving  the  picture 
of  a  traumatic  coxa  vara.  In  all  of  the  author's  cases  there  was  consid- 
erable limitation  of  motion.  Pseudarthrosis  also  occurs.  In  one  of  the 
author's  cases  two  years  after  the  injury  there  was  still  no  union  between 
the  head  and  neck,  the  head  lying  free  in  the  cavity.  If  bony  union 
occurs,  the  epiphyseal  line  is  lost;  later  the  growth  of  the  femur  is 
inhibited,  slightly,  however,  as  the  growth  in  length  is  chiefly  from  the 
lower  epiphysis. 

Treatment. — The  treatment  in  recent  cases  is  preferably  the  extension 
splint;  in  the  absence  of  shortening,  a  well-fitting  plaster  splint.  In 
cases  of  pseudarthrosis  or  malunion  with  deformity  and  great  limita- 
tion of  motion  the  author  has  obtained  good  results  by  excising  the 
Vol.  III.— 29 


450  INJURIES  OF  THE  HIP. 

head.     In  traumatic  coxa  vara  with  marked  functional  loss  subtrochan- 
teric osteotomy  is  advisable. 

Separation  of  the  Epiphysis  at  the  Great  Trochanter. — Poland  col- 
lected 8  authentic  cases  of  this  kind;  3  were  found  on  autopsy.  The 
cause  was  always  direct  violence.  The  patients  were  all  under  seventeen 
years.  Any  marked  upward  displacement  of  the  trochanter  was  usually 
prevented  by  the  integrity  of  the  numerous  tendons  and  ligaments. 
Soft  crepitus  was  occasionally  elicited,  especially  by  downward  pressure. 
The  condition  of  the  soft  parts  determines  the  subsequent  function. 
The  latter  may  be  very  good;  it  also  depends  upon  whether  or  not  the 
trochanter  follows  the  rotation  of  the  thigh.  If  displaced  upward,  it  may 
simulate  a  dislocated  head.  As  the  trochanter  is  covered  with  tissues 
poorly-supplied  with  blood  and  its  nutrition  is  obtained  from  the  shaft, 
suppuration  takes  place  easily,  especially  if  on  a  diagnosis  of  contusion 
the  patient  is  allowed  to  go  about  during  the  first  few  days. 


GUNSHOT-WOUNDS  OF  THE  HIP-JOINT. 

Gunshot-wounds  of  the  hip-joint  are  not  very  common.  In  the 
statistics  of  the  Franco-Prussian  War  (1870-71)  there  were  only  128 
cases.  In  the  recent  South  African  War  Kuttner  and  Makins  each  saw 
only  1  case  of  small-calibre  wound  of  the  hip-joint.  Most  of  the  wounds 
were  from  before  backward  or  in  the  reverse  direction,  v.  Langenbeck 
assumes  that  a  probable  diagnosis  of  involvement  of  the  hip-joint 
can  be  made  if  the  opening  is  near  the  great  trochanter  and  anterior- 
superior  spine,  namely,  if  the  wound  of  entrance  or  exit  is  H  inches 
below  the  anterior-superior  spine.  If  the  wound  lies  close  in  front  of 
or  behind  the  great  trochanter,  involvement  of  the  neck  is  very  prob- 
able. A  bullet  entering  in  front  of  the  tuber  ischii  and  emerging  behind 
the  great  trochanter  probably  involves  the  head  of  the  femur  and  portion 
of  the  acetabular  margin.  The  damage  to  the  joint  varies  from  simple 
penetration  of  the  capsule  without  injury  of  the  joint-surfaces,  fracture 
of  the  head,  of  the  great  or  lesser  trochanter,  or  a  simple  penetrating 
wound  of  the  neck,  to  very  extensive  comminuted  fracture  of  the  entire 
upper  end  of  the  femur  and  the  joint  cavity.  The  bullet  is  occasionally 
found  lodged  in  the  head. 

Gunshot  fractures  of  the  femur  and  pelvis,  especially  of  the  horizontal 
ramus  of  the  pubis,  not  infrequently  involve  the  hip-joint  through 
radiating  fissures.  If  the  bullet  perforates  the  acetabulum,  it  enters 
the  pelvis  and  may  injure  the  viscera — for  example,  the  bladder  or 
rectum.  Inversely'  the  bullet  may  enter  the  hip-joint  through  the 
abdomen  or  pelvis.  Complications  have  been  observed,  such  as  wounds 
of  the  bladder  and  rectum  with  the  discharge  of  urine  or  feces  through 
the  shot-wound,  also  wounds  of  the  large  vessels  in  the  thigh  and  the 
large  nerves,  the  crural  and  sciatic.  A  blind  shot-track,  namely,  a 
wound  of  entrance  but  no  wound  of  exit,  is  a  frequent  occurrence  in 
shot-wounds  of  the  hip. 


QUNSHOTtWOUNDS  OF  THE  HIP  JOINT.  45] 

Diagnosis. — The  diagnosis  of  wounds  of  the  hip-joint  may  be  very 
difficult,  particularly  if  the  patient  is  able  to  be  aboul  for  days  or  weeks 
after  the  injury.  The  x-ray  makes  it  much  easier  at  the  presenl  time, 
however.  Usually  the  direction  of  the  wound  should  guide  the  surgeon; 
further,  the  attitude  of  the  patient  at  the  time  of  injury,  v.  Langenbeck 
assumes  involvement  of  the  hip-joint  if  the  wounds  of  entrance  and 
exit  lie  within  a  triangle,  the  base-line  of  which  cuts  the  greater  trochanter 
with  the  apex  at  the  anterior-superior  spine. 

If  the  capsule  alone  is  involved  or  the  damage  to  the  bone  is  slight, 
the  symptoms  in  recent  eases  are  often  atypical.  The  first  important 
symptoms  an'  the  onset  of  inflammation,  distention  of  the  capsule,  dis- 
charge of  pus  or  sanies,  and  severe  pain,  in  connection  with  the  very  im- 
portant symptom  noted  by  v.  Langenbeck,  namely,  a  swelling  which  lifts 
up  the  vessels  of  the  thigh.  The  traumatic  inflammation  usually  begins 
in  the  second  week  after  the  injury,  hut  may  be  hastened  by  external 
circumstances,  such  as  bad  transportation  or  injudicious  moving  of  the 
limb.  If  the  inflammation  appears  very  late,  it  may  have  been  trans- 
mitted, assuming  that  the  joint  was  uninjured  primarily  and  that  the 
bullet  damaged  only  the  periarticular  soft  parts.  In  the  absence  of  a 
wound  of  exit  the  diagnosis  is  often  possible  if  the  symptoms  of  com- 
minution of  the  neck  are  present,  namely,  outward  rotation,  shortening, 
crepitus,  etc.  If  the  diagnosis  is  not  positive,  the  injury  should  be 
treated  as  one  of  the  joint.  Probing  or  manipulation  should  be  strictly 
avoided. 

Prognosis. — Thus  far  the  prognosis  of  shot-wounds  of  the  hip-joint 
has  been  very  bad,  the  chief  danger  being  that  of  infection,  as  its  develop- 
ment is  facilitated  by  the  hidden  position  of  the  joint  and  the  discharge 
of  pus  prevented  by  the  thick  covering  of  the  soft  parts.  The  prospect 
of  recovery  diminishes  with  the  severity  of  the  injury  and  the  number 
of  complications.  Of  the  128  shot-wounds  of  the  hip  in  the  Franco- 
Prussian  War,  the  pre-antiseptic  period,  102  died,  mostly  of  pyaemia, 
the  4  cases  amputated  were  fatal,  and  of  the  27  resected  25  were  fatal. 
Of  the  97  non-operated  and  treated  conservatively,  73  died.  The 
2  cases  of  Kiittner  and  Makins  mentioned  above,  which  were  treated 
conservatively,  recovered.  Ankylosis  is  the  almost  uniform  result  of 
shot-wounds  of  the  hip,  usually  with  more  or  less  shortening  and 
anomalous  position  of  the  limb.  The  joint  was  often  dislocated.  The 
period  of  recovery  averaged  6  months. 

Treatment. — Modern  principles  are  opposed  to  any  further  attack 
upon  the  wound;  the  wounds  of  entrance  and  exit  should  be  covered 
with  an  antiseptic  dressing  and  the  extremity  immobilized  as  far  as 
possible.  Even  in  the  field  hospital  with  all  the  required  aids  at  hand, 
conservative  treatment  is  the  rule  and  the  extension  splint  of  the  greatest 
value.  Resection  of  the  upper  end  of  the  femur  and  tamponade  of  the 
joint  are  only  indicated  by  severe  suppuration.  Amputation  at  the 
hip  is  indicated  primarily  or  secondarily  for  very  extensive  laceration 
of  the  soft  parts  produced  by  heavy  ordnance. 


CHAPTER   XXIV. 

DISEASES  OF  THE  HIP. 

INFLAMMATION  OF  THE  HIP-JOINT  (NOT  INCLUDING 
TUBERCULOSIS) 

Pathological  Anatomy. — Before  describing  the  different  clinical  forms 
of  inflammation  of  the  hip-joint  it  is  well  to  consider  the  pathological 
anatomy,  many  special  features  of  which  can  be  reconstructed  by  reason 
of  their  interrelationship.  The  primary  synovial  forms  in  which  the 
cartilage  is  uninvolved,  or  involved  only  secondarily,  are  to  be  distin- 
guished from  those  forms  following  osteomyelitis  or  ostitis  of  the 
articular  ends  of  the  bones.  Formerly  all  the  varieties  of  coxitis  to  be 
considered  here  were  included  in  the  first  group;  to-day  many  are 
placed  in  the  second — in  fact,  Konig  and  Brims  are  convinced  that 
the  large  majority  of  all  acute  and  subacute  cases  of  coxitis  in  childhood 
and  adolescence  should  be  regarded  as  the  result  of  osteomyelitis  or 
ostitis  of  the  articular  ends. 

Primary  synovitis,  as  in  the  other  joints,  may  be  serous,  serofibrinous, 
hemorrhagic,  or  purulent.  Coxitis — this  applies  to  the  serous  and 
fibrinous  as  well  as  purulent  inflammations — may  be  distinguished  by 
predominance  of  fluid  in  the  joint  or  of  infiltration  in  the  synovialis 
or  in  the  periarticular  tissue,  or  in  both.  The  course  varies  neces- 
sarily with  the  form  of  inflammation.  In  the  non-purulent  type,  if  the 
exudation  of  fluid  in  the  joint  predominates,  there  will  be  an  increasing 
distention  of  the  capsule;  if  there  is  chiefly  an  infiltration  of  the  syno- 
vialis or  of  the  periarticular  tissue,  there  will  be  adhesions  between  the 
contiguous  synovial  surfaces  at  an  early  period,  or  shrinkage  of  the 
capsule  and  the  danger  of  stiffness.  In  the  first  case  the  danger  is 
chiefly  that  of  dislocation.  Plastic  infiltration  of  the  joint-membrane 
represents  a  severer  form  of  disease  than  exudation. 

Purulent  coxitis  behaves  similarly.  If  accompanied  chiefly  by  exuda- 
tion, one  may  hope  to  control  the  suppuration  by  timely  drainage — in 
fact,  in  spite  of  profuse  suppuration  in  the  cavity,  almost  complete 
recovery  without  essential  functional  disturbance  has  been  seen  after 
early  removal  of  the  pus  or  even  after  spontaneous  perforation.  These 
are  the  cases  of  suppuration  of  the  joint  described  by  v.  Volkmann  as 
"catarrhal."  At  the  onset  the  exudate  is  a  thick,  creamy  pus  mixed 
with  yellow  shreds;  later  it  is  a  pure  more  or  less  slimy  pus.  It  rarely 
results  in  shrinkage  of  the  capsule  or  the  consequent  functional  dis- 
turbances. Purulent  infiltration  of  the  synovial  membrane  is  by  far 
the  most  severe  variety.  A  profuse  exudation  of  fibrin  in  the  tissues 
(452) 


INFLAMMA  TION  OF  THE  HIP- JOINT.  453 

introduces  the  danger  of  plastic  infiltration,  the  serious  consequences 

of  which  for  the  joint  have  only  recently  been  appreciated;  this  danger 
is  increased  by  early  destruction  of  the  cartilage;  the  preservation  of 
the  entire  limb  is  placed  in  question  by  a  tendency  to  periarticular 
,  abscesses. 

In  primary  ostitis  one  has  to  distinguish  between  an  ostitis  of  the 
cartilage,  usually  causing  separation  of  the  epiphysis,  and  an  osseous 
focal  inflammation  of  the  head  and  cavity.  Ostitis  of  the  cartilage 
varies  in  pathological  significance;  it  includes  the  severe  cases  of 
suppuration  ending  in  death  or  complete  destruction  of  the  parts — 
and  those  in  which  separation  of  the  epiphysis  occurs  almost  entirely 
without  acute  symptoms  in  the  guise  of  a  hydrops  of  the  joint.  In 
very  severe  cases  the  ostitis  may  extend  beyond  the  trochanters  and 
cause  separation  of  their  epiphyses.  Usually  the  surgeon  has  to  deal 
with  the  focal  ostitis  of  the  head  and  acetabulum  described  by  Schede, 
Albert,  and  Muller,  and  which  is  similar  to  the  focal  form  of  tuber- 
culosis. The  foci  vary  in  size  from  that  of  a  pea  to  that  of  a  walnut, 
and  are  filled  with  granulations  or  peculiar  white,  chalky,  thick  paste 
or  thick  yellow  pus.  Usually  they  contain  small  or  large  sequestra 
distinguished  by  an  intense  yellow  color.  The  infection  of  the  joint  takes 
place  from  these  foci  in  the  form  of  a  purulent  or  cloudy  serous  synovitis. 

Traumatic  Coxitis. — The  mildest  form  of  serous  inflammation  of 
the  hip-joint  is  represented  by  the  reaction  of  the  synovial  membrane  to 
trauma  which  has  torn  the  capsule  without  any  essential  damage  to 
the  joint.  A  sharp  pain  is  felt  at  the  moment  of  injury,  but  motion 
is  not  impaired.  Later,  motion  is  painful  and  limited.  Gradually  a 
slight  swelling  appears  at  the  hip,  hardly  recognizable  in  well-built 
individuals,  resulting  from  the  partly  serous,  partly  hemorrhagic, 
extravasation  in  and  around  the  joint.  Under  appropriate  treatment 
the  symptoms  subside  in  a  relatively  short  time;  infrequently  a  chronic 
hydrarthrosis  develops  with  thickening  and  tenderness  of  the  capsule. 
In  intracapsular  fracture  there  may  be  inflammation  in  and  about 
the  joint,  occasionally  followed  by  organization  of  the  blood-clot  in 
the  joint  and  severe  and  permanent  stiffness. 

Coxitis  following  Infectious  Diseases. — A  large  percentage  of  the 
cases  of  primary  synovial  coxitis  follow  the  numerous  infectious  dis- 
eases— scarlet  fever,  measles,  diphtheria,  pneumonia,  typhoid,  smallpox, 
gonorrhoea — and  may  be  serofibrinous  or  purulent.  They  are  produced 
by  the  specific  germ  of  the  infectious  disease.  Although  the  specific 
micro-organisms  of  only  a  certain  number  of  the  above  infectious 
diseases  are  known,  bacteriological  examination  has  established  the 
identity  of  the  primary  infection  and  the  arthritis  with  reference  to 
those  which  are  known.  Typhoid  bacilli,  Frankel's  diplococcus,  the 
meningococcus  and  gonococcus  have  been  found  repeatedly  in  pure 
cultures,  in  other  instances  mixed  with  staphylococcus  and  strepto- 
coccus, and  usually  mixed  in  cases  of  severe  suppuration. 

The  occasional  negative  results  given  in  the  literature  cannot  weaken 
the  etiology;  the  difficulty  of  demonstrating  the  gonococcus,  for  example, 


454  DISEASES  OF  THE  HIP. 

and  the  destruction  of  the  typhoid  bacilli  by  overgrowth  of  the  ordinary 
pyogenic  forms,  sufficiently  explain  the  negative  results.  The  specific 
germs  of  the  infectious  diseases  are  apparently  able  to  produce  only  the 
serofibrinous  and  mild  purulent  cases  of  coxitis.  The  common  pyogenic 
forms  are  almost  always  found,  either  alone  or  combined,  in  the  strictly 
purulent  processes,  so  that  the  addition  of  staphylococci  or  strepto- 
cocci may  be  regarded  as  essential  to  produce  suppuration.  We  are 
naturally  compelled  to  draw  conclusions  by  analogy  in  regard  to  the 
etiology  of  inflammations  of  the  hip-joint  in  infectious  diseases  the 
germ  of  which  is  unknown.  It  is  impossible  to  specialize  here  with 
reference  to  the  course  <>\'  coxitis  in  the  various  inf^Lious  diseases. 
The  author  will  confine  himself  to  giving  the  cmnJI^^general  and 
mentioning  the  peculiarities. 

In  the  majority  of  cases  after  temporary  attacks  of  pain  in  various 
joints,  occasionally  with  rise  of  temperature,  there  is  an  effusion 
in  the  hip-joint  alone,  or  also  in  other  joints,  at  the  height  of  the  disease 
or  during  convalescence.  The  effusion,  usually  serous  or  serofibrinous, 
generally  subsides  rapidly  or  persists  and  becomes  chronic,  finally  with 
dislocation  and  hydrops.  Less  frequently  there  is  inflammatory  swelling 
of  the  capsule  and  soft  parts  about  the  joint,  unaccompanied  by  any 
great  amount  of  exudation  but  threatening  the  function  of  the  joint. 
The  purulent  inflammations  usually  run  the  course  of  a  "catarrhal" 
suppuration,  but  severe  suppuration  followed  by  destruction  of  the 
parts,  ankylosis,  or  even  death,  does  occur.  The  gonorrhceal  and 
typhoid  forms  require  special  mention,  the  first  on  account  of  its  ten- 
dency to  produce  ankylosis,  the  latter  on  account  of  the  frequency  of 
dislocation. 

Gonorrhceal  coxitis  is  more  frequent  than  was  formerly  supposed;  it 
may  be  either  in  the  form  of  a  serous  effusion  or  of  a  severe  fibrinous 
inflammation  with  marked  swelling  of  the  tissues  about  the  joint.  In 
the  latter  case  the  tendency  to  ankylosis  is  greater  than  in  any  other 
disease,  and  goes  hand  in  hand  with  extensive  adhesions  and  a  ten- 
dency to  deformation.  Under  this  head,  according  to  Kdnig  and  Nasse, 
belongs  the  dreaded  puerperal  coxitis,  occurring  usually  in  the  second 
week  with  severe  pain  and  swelling  of  the  extremities,  followed  by 
ankylosis.  Actual  suppuration  is  rare,  but  is  then  extremely  severe 
and  often  fatal. 

The  serous  form  may  also  end  badly,  either  in  spontaneous  disloca- 
tion or  recurrence  and  proliferation.  According  to  Nasse,  the  chronic 
inflammations,  either  as  a  hydrarthrosis  or  with  multiple  villiform 
growths  with  or  without  effusion,  are  usually  gonorrhceal. 

Fortunately  the  course  is  usually  not  so  severe.  In  the  majority  of 
cases  it  is  as  follows:  Accompanied  by  a  moderate  temporary  rise  of 
temperature,  occasionally  high  at  the  onset,  there  are  more  or  less 
diffuse  darting  and  shooting  pains  in  various  joints.  The  arthritis  (mon- 
arthritis  or  polyarthritis)  follows;  in  a  few  days  the  pain  diminishes, 
the  temperature  drops,  the  swelling  subsides;  in  favorable  cases  return 
to  normal  in  eight  to  fourteen  days;  in  part  of  the  cases  recurrence  and 


INFLAMMATION  OF  THE  HIP-JOINT.  455 

recovery  after  several  years.  Gonorrhoea!  inflammation  of  the  hip-joint 
occurs  in  young  children,  hut  has  a  favorable  course. 

Typhoid  coxitis  is  characterized  by  an  effusion  distending  the  capsule, 
often  without  symptoms,  and  followed  by  unexpected  spontaneous  dis- 
location. Next  to  typhoid,  scarlet  fever  and  smallpox  are  most  apt  to 
produce  spontaneous  dislocation,  hut  to  a  lesser  degree. 

The  syphilitic  affections  which  occur  in  the  joints,  not  with  least  fre- 
quency in  the  hip-joint,  as  a  simple  inflammation  without  specific  new 
formation,  are  to  be  classified  among  the  inflammations  of  the  joint 
following  infectious  diseases.  The  hip-joint  may  be  affected  alone  or 
simultaneousMwith  other  joints.  The  exudative  swellings  of  the  joints 
at  the  hcgil^J^of  the  second  stage  of  syphilis,  often  accompanied  by 
fever  and  characterized  by  their  painfullness,  are  well  known.  They  may 
occur  in  children  with  congenital  syphilis,  often  with  violent  symptoms 
simulating  suppuration,  so  that  operation  has  frequently  been  performed 
where  specific  treatment  would  have  been  proper.  Primary  purulent 
syphilitic  coxitis  is  rare,  and  is  seen  more  particularly  in  children  with 
hereditary  lues.  With  improper  treatment  it  may  merge  into  a  chronic 
hydrops  with  swelling  of  the  capsule. 

Acute  articular  rheumatism  is  a  term  still  applied  to  the  most  diverse 
forms  of  infectious  coxitis.  It  would  be  well  to  limit  the  term  to  those 
inflammations  of  the  joint  which  react  to  salicylic  acid.  In  the  mild 
cases  the  surgeon  is  dealing  with  a  serous  inflammation,  in  the  severe 
cases  sometimes  followed  by  shrinkage  of  the  capsule,  with  a  fibrinous 
inflammation.  Following  Konig's  example,  the  author  does  not  classify 
purulent  coxitis  with  acute  articular  rheumatism  merely  because  its 
clinical  course  is  similar,  and  in  those  instances  in  which  the  etiology 
is  lacking  he  prefers  to  admit  openly  the  inadequacy  of  our  present 
knowledge  rather  than  attempt  to  conceal  it  behind  a  term  which 
causes  so  much  confusion  as  acute  articular  rheumatism.  Sometimes 
a  hidden  focus  of  suppuration,  sometimes  a  mild  undetected  diph- 
theria, is  responsible  for  the  involvement  of  the  hip-joint. 

Coxitis  in  Infancy. — The  etiology  of  the  majority  of  cases  of  primary 
synovial  coxitis  of  childhood,  especially  in  early  infancy,  is  almost 
unknown.  Above  the  author  has  mentioned  syphilitic  and  gonorrhceal 
coxitis,  and  must  state  here  expressly  that  gonorrhoea  and  gonorrhceal 
coxitis  are  far  more  frequent  in  young  children  than  is  generally  recog- 
nized. In  young  girls  gonorrhceal  vulvovaginitis  sometimes  occurs 
almost  endemically  as  the  result  of  infectious  defloration,  polluted  cloth- 
ing, etc.  In  these  cases  the  vulvovaginitis  is  the  cause  of  the  joint- 
disease.    In  the  newborn  it  is  an  intrapartum  infection. 

Nevertheless  one  frequently  sees  purulent  synovitis  of  the  hip-joint 
without  recognizable  cause  (scarlet  fever,  measles,  etc.)  in  which, 
above  all,  tuberculosis  and  syphilis  can  be  excluded  with  certainty. 
The  effusion  in  the  joint  develops  with  fever,  pain,  swelling,  and  usually 
redness  of  the  surrounding  soft  parts,  and  is  either  incised  or  perforates 
spontaneously.  The  pus  is  very  viscid,  the  synovial  membrane  deeply 
red  and  greatly  swollen.    The  course  is  usually  favorable,  recovery  gener- 


456  DISEASES  OF  THE  HIP. 

ally  following  with  no  or  only  slight  impairment  of  motion.  Dislocation 
may  occur.  Destruction  of  the  joint  is  rare;  even  then  the  mobility  is 
fairly  good.  The  picture  in  general  is  therefore  that  of  a  catarrhal 
suppuration  of  the  joint,  except  that  the  pain  is  a  prominent  symptom. 
Death  has  been  observed  only  in  the  case  of  very  weak  children. 

These  various  forms  of  coxitis  are  most  frequently  seen  during  the 
first  year,  rarely  after  the  fourth  year.  Krause  found  streptococci  in 
the  pus  in  2  instances;  in  the  majority  of  the  cases  accurate  bacterio- 
logical examinations  are  lacking.  Certainly  paths  of  entrance  for  the 
micro-organisms  are  not  wanting  in  earliest  infancy,  and  in  the  occur- 
rence of  septic  infections  in  this  period  an  important  role  has  been 
recently  ascribed  to  the  Bacillus  coli  communis  entering  the  circulation 
from  the  intestine.  It  is  most  probable  that  in  these  cases  a  primary 
osteomyelitis  of  the  shaft  of  the  femur  is  present. 

Coxitis  by  Direct  Infection. — Primary  synovial  coxitis  may  be  the 
result  of  direct  infection  from  erysipelas  advancing  over  the  hip,  from 
an  adjacent  phlegmon,  or  a  penetrating  wound  of  the  joint.  In  the  first 
two  instances  the  surgeon  is  usually  confronted  with  very  severe  sup- 
puration of  the  joint  threatening  the  entire  extremity  or  life;  in  the 
latter  instance,  namely,  in  penetrating  wounds,  the  severity  of  the  process 
depends  upon  the  virulence  of  the  bacteria  in  the  wound. 

Symptoms. — In  penetrating  wounds  the  oozing  synovia  rapidly  be- 
comes cloudy  and  purulent.  The  joint  feels  hot,  is  extremely  tender, 
the  least  movement  arousing  vehement  expression  of  pain;  the  con- 
stitutional symptoms  depend  upon  the  severity  of  the  infection.  In 
the  worst  cases  there  may  be  perforation  of  the  capsule,  abscesses  about 
the  joint,  thrombosis  of  the  adjacent  vessels,  and  metastatic  abscesses 
in  the  inner  organs.  Nowhere  does  the  fate  of  the  patient  depend  more 
upon  early  and  energetic  surgical  treatment  than  in  these  suppurations 
of  the  hip-joint  by  immediate  infection. 

Diagnosis. — The  diagnosis  of  all  the  above-mentioned  inflammations 
of  the  hip-joint  as  such  is  usually  simple;  the  differential  diagnosis 
between  the  etiologically  contrasted  forms  is  often  difficult.  It  is 
not  sufficient  to  diagnose  a  serous  or  a  catarrhal  inflammation  of  the 
joint,  as  the  case  may  be;  the  surgeon  should  always  try  to  find  out  the 
cause.  The  author  need  only  mention  the  confounding  of  syphilitic 
affections  in  young  children,  accompanied  by  acute  symptoms,  with 
severe  purulent  processes,  and  the  confounding  of  focal  ostitis,  giving  the 
symptoms  of  chronic  articular  rheumatism,  with  the  above.  One  should 
be  particularly  careful  about  the  diagnosis  "articular  rheumatism," 
and  not  treat  expectantly  where  immediate  operation  is  required.  A 
decision  as  to  the  severity  of  the  inflammation  is  given  by  the  intensity 
of  the  general  and  local  symptoms,  and  in  doubtful  cases  the  character 
of  the  disease  will  be  determined  by  aspiration. 

Treatment. — The  treatment  is  on  general  surgical  principles.  Recent 
traumatic  effusion  demands  appropriate  immobilization  of  the  joint, 
massage,  and  compression  after  disappearance  of  the  first  inflammatory 
symptoms.     In  immobilizing  the  lower  extremity — this  applies  to  all 


INFLAMMATION  OF  THE  HIP-JOINT. 


457 


cases — the  joint  should  be  placed  in  the  position  giving  the  best  function 
in  case  of  stiffening,  namely,  slight  flexion  and  abduction.  If  there  is 
a  hsemarthrosis  and  the  blood  is  not  rapidly  absorbed,  it  should  be 
removed  by  puncture  to  prevent  organization  and  stiffness.  Also  to 
prevent  stiffness  immobilization  should  not  be  continued  too  long  and 
passive  motion  begun  early. 

In  gonorrhoea]  coxitis,  if  purely  serous,  aspiration  and  injection  of  a 
3  per  cent,  carbolic-acid  solution  are  beneficial.  Recently  Schuchardt 
used  a  1  per  cent,  solution  of  protargol,  in  1  instance  with  good  result. 
By  timely  aspiration  dislocation  is  prevented.     If  the  swelling  is  chiefly 

Fig.  287. 


Pathological  dislocation  following  scarlet  fever. 

in  the  capsule,  the  injection  may  be  made  into  the  capsule  in  various 
places  with  a  Pravaz  syringe.  For  suppuration  free  incision  is  indicated, 
followed  by  irrigation,  packing  or  drainage,  or  eventually  resection. 

As  to  spontaneous  dislocation  of  the  hip,  Degez  has  made  a  careful 
compilation  of  81  dislocations  following  typhoid,  rheumatism,  scarlet 
fever,  variola,  gonorrhoea,  influenza,  and  erysipelas.  He  showed  that 
it  was  possible  to  effect  reduction  some  time  afterward,  the  manipulation 
being  the  same  as  for  traumatic  dislocation,  namely,  traction,  counter- 
traction,  and  direct  pressure.  The  accompanying  illustration  (Fig.  2S7) 
is  of  a  dislocation  following  scarlet  fever  which  was  reduced  with  com- 


458  DISEASES  OF  THE  HIP. 

plete  success,  as  can  be  seen,  four  months  later.  Operation  is  indicated 
if  repeated  attempts  at  reduction  are  unsuccessful. 

Coxitis  from  Acute  Osteomyelitis. — Recently  P.  v.  Brans  and  Honsell 
published  an  excellent  work  from  the  Tubingen  clinic  on  acute  osteo- 
myelitis of  the  hip-joint,  v.  Volkmann,  Schede,  Stahl,  W.  Miiller,  Albert, 
and  Kblisko  haying:  previously  studied  the  disease  and  its  secjuelfe. 
The  following  description  is  taken  from  the  data  of  v.  Brans  and 
Honsell. 

In  the  last  forty  years  106  cases  of  osteomyelitis  of  the  hip  were  seen 
in  the  Tubingen  clinic,  in  contrast  to  500  of  the  lower  end  of  the  femur. 
Only  3  of  these  were  attributed  to  a  cold;  15  were  referred  to  trauma, 
such  as  a  blow,  fall  upon  the  hip,  slipping,  etc.  At  the  onset  of  the 
disease  12  patients  were  from  one  to  five  years  old,  25  from  fiye  to 
ten,  43  from  ten  to  fifteen,  23  from  fifteen  to  twenty,  2  from  twenty  to 
twenty-five,  and  only  1  twenty-six  years  old.  Males  were  represented 
somewhat  more  frequently;  there  was  no  difference  in  the  frequency  of 
the  disease  on  the  two  sides;  in  4s  cases  the  process  was  on  the  right, 
in  40  the  left,  in  12  bilateral. 

Pathological  Anatomy. — The  disease  may  start  in  the  femur  or 
acetabulum.  Inflammation  of  the  epiphysis  alone  is  very  rare.  (W. 
Miiller,  Jordan,  Lannelongue.  More  often  the  upper  end  of  the  shaft 
alone  is  affected,  or  the  neck  with  or  without  the  trochanter,  but  usually 
the  shaft  and  epiphysis  are  involved  simultaneously;  in  addition  the 
shaft  of  the  femur  may  be  involved  partially  or  entirely.  It  is  best  to 
designate  the  disease  of  the  entire  upper  part  of  the  femur  to  the  leyel  of 
the  lesser  trochanter  as  epiphyseal  in  the  broader  sense,  as  indicated  by 
Jordan,  Miiller,  Schede,  Stahl,  v.  Brims,  and  Honsell.  In  osteomyelitis 
of  the  epiphysis,  in  contrast  to  disease  of  the  shaft,  the  individual  foci 
remain  circumscribed  for  a  long  time.  The  foci  develop  into  confluent 
or  multiple  cavities  filled  with  pus  or  granulations  and  sequestra,  the 
latter  usually  small  and  derived  from  the  spongiosa,  rarely  from  the 
cortex.  The  sequestra  may  be  gradually  absorbed  or  remain  for  years. 
There  is  rarely  any  extensive  formation  of  new  bone  about  the  foci,  but 
rather  atrophy  and  absorption  of  the  bone  involved. 

In  the  upper  end  of  the  femur  there  is  occasionally  a  more  diffuse 
purulent  infiltration  of  the  spongiosa.  as  first  described  by  v.  Volkmann 
and  Leveque,  and  recently  confirmed  by  v.  Brtmsand  Honsell.  Usually, 
however,  there  are  discrete  foci  of  infiltration  and  suppuration  scattered 
through  the  head,  neck,  and  trochanter.  These  cavities  do  not  generally 
contain  any  sequestra.  Sometimes  there  is  extensive  necrosis;  for 
example,  in  a  case  of  v.  Brims  and  Honsell  the  entire  upper  end  of  the 
femur  from  the  intertrochanteric  line  was  transformed  into  a  sequestrum 
only  loosely  connected  with  the  shaft. 

The  inflammation  may  come  to  a  standstill  within  the  bone  without 
perforation,  but  usually  advances.  If  the  foci  are  near  the  surface, 
perforation  into  the  joint  or  into  the  tissues  about  the  joint  follows  the 
destruction  of  the  cartilage  or  periosteum;  there  is  then  a  more  or  less 
extensive  irregular  loss  of  substance  on  the  surface  of  the  neck,  head, 


INFLAMMATION  OF  THE  HIP- JOINT.  459 

and  trochanters.  If  the  defects  are  numerous,  the  appearance  may  be 
that  of  a  tuberculous  coxitis,  particularly  if  covered  with  flabby  yellow 
granulations.  (W.  Muller.)  If  the  foci  lie  deeper  in  the  bone,  they  may 
perforate  directly  outward  or  through  superficial  cavities  and  occasion 
considerable  loss  of  function,  even  complete  destruction  of  the  head  and 
neck. 

The  foci  close  to  the  epiphyseal  line  are  especially  important.  To  a 
certain  degree  the  cartilage  forms  a  natural  barrier  against  extension 
of  the  inflammation,  and  is  therefore  rarely  perforated  over  a  large  area. 
Consequently  the  inflammation  more  often  advances  along  the  epiphyseal 
line,  loosening  the  epiphysis  and  finally  separating  it  from  the  shaft. 
The  epiphysis  may  be  completely  necrotic  and  the  head  be  found  as  a 
free  body  in  the  joint.  The  epiphysis  may  become  adherent  again, 
partly  to  the  femur,  partly  to  the  acetabulum.  The  epiphyses  of  the 
trochanters  may  be  loosened  and  separated  in  the  same  way,  or  the 
neck  may  be  separated  partly  or  entirely  beyond  the  epiphyseal  line. 

If  the  disease  involves  the  acetabulum  primarily  or  secondarily,  there 
may  be  either  small  defects,  soft  discolored  spots  in  the  cartilage,  or 
large  portions  of  the  cartilage  may  be  destroyed  and  the  underlying 
bone  appear  rough,  eroded,  and  filled  with  granulations;  finally  there 
may  be  deep  loss  of  substance,  necrosis,  and  perforation  of  the  wall  and 
margin  of  the  cavity.  In  primary  osteomyelitis  of  the  acetabulum,  as 
described  recently  by  Bardenheuer  and  Obalinsky,  in  the  early  stages 
there  are  circumscribed  foci,  with  or  without  sequestra,  and  mostly 
close  to  the  Y-cartilage,  later,  destruction  of  the  cartilage,  perforation 
of  the  acetabulum,  and  extensive  destruction  of  the  ilium  or  even  of 
the  more  distant  parts  of  the  pelvis.  Occasionally  in  osteomyelitis  of 
the  pelvic  bones  a  periostitic  abscess  may  perforate  indirectly  into  the 
hip-joint.     (Fleury,  Schede,  and  Lannelongue.) 

Inflammation  of  the  synovialis  of  the  hip-joint  accompanies  the 
disease  of  the  bone,  varying  from  a  mild  adhesive  serous  or  catarrhal 
inflammation  to  suppuration  and  sanious  ulceration  of  the  joint.  Per- 
foration of  a  large  bony  focus  or  a  periarticular  abscess  into  the  joint 
may  cause  severe  suppuration  and  destruction  of  the  cartilage,  liga- 
mentum  teres,  and  capsule.  The  milder  forms  of  inflammation  are 
usually  seen  in  connection  with  small  osseous  foci  which  have  existed 
for  some  time  and  lead  to  the  formation  of  adhesions  between  the 
contiguous  synovial  surfaces  of  the  joint  before  perforating. 

So  far  only  the  acute  stage  of  the  first  weeks  and  months  of  osteomy- 
elitis have  been  discussed.  If  recovery'  occurs  eventually,  changes  are 
always  found  in  the  bone  which  greatly  affect  the  future  usefulness  of 
the  limb.  Exceptionally  thickening  of  the  upper  end  of  the  femur  is 
found,  especially  the  trochanteric  portion,  and  even  less  frequently  of 
the  intra-articular  portion.  (Jordan,  Albert,  W.  Muller,  v.  Brims,  and 
Honsell.) 

There  may  be  focal  or  diffuse  sclerosis  of  the  affected  area  or  marked 
atrophy  of  the  upper  end  of  the  femur.  The  deformity  depends  upon 
the  amount  of  destruction,  the  condition  of  the  epiphyseal  cartilage,  and 


460  DISEASES  OF  THE  HIP. 

the  tension  and  pressure  in  the  affected  parts.  There  may  be  a  char- 
acteristic depression  of  the  head  at  the  epiphyseal  line,  often  with 
broadening  of  the  head,  the  mushroom  form.  (Albert  and  Kolisko, 
W.  Miiller,  v.  Bruns,  and  Honsell.)  Or  the  head  may  be  smaller  than 
normal,  the  head  and  neck  being  more  cylindrical,  oval,  or  conical. 

The  neck  is  more  frequently  deformed  than  the  head.  It  may  be  so 
shortened  that  the  head  is  attached  to  the  trochanter.  It  is  very  fre- 
quently bent,  as  described  first  by  v.Volkinann,  later  by  Schede  and  Stahl, 
Diesterweg,  and  W.  Miiller.  According  to  v.  Bruns  and  Honsell,  three 
types  of  curvature  may  be  distinguished:  the  entire  upper  end  of  the 
femur,  including  the  trochanters,  is  bent  downward  and  inward;  the 
neck  is  bent  downward  at  the  base;  the  neck  is  bent  at  the  head  toward 
the  tip  of  the  lesser  trochanter.  The  shaft  of  the  femur  may  also  be 
curved.  In  contrast  to  the  upper  end  of  the  femur,  the  acetabulum 
reacts  with  a  most  prolific  production  of  new  bone.  The  wall  of  the 
acetabulum  becomes  thickened,  bridges  of  bone  spring  from  one  side 
of  the  cavity  to  the  other  or  to  the  femur;  the  entire  cavity  may  be  rilled 
and  large  osteophytes  form  around  it.  "Wandering"  of  the  cavity, 
which  is  observed  so  frequently  in  tuberculous  coxitis,  is  not  rare. 

The  permanent  changes  in  the  joint  are  proportional  to  the  duration 
and  intensity  of  the  inflammation.  If  the  inflammation  is  slight,  the 
resorption  of  the  exudate  may  be  followed  by  adhesions  between  the 
capsule  and  surface  of  the  cartilages  resulting  in  severe  loss  of  motion. 
If  the  destruction  in  the  joint  was  greater,  extensive  adhesions  form 
between  the  articular  surfaces,  the  capsule  and  periarticular  soft  parts 
are  transformed  into  thick,  dense  fibrous  tissue,  the  joint  becomes 
ankylosed.  That  a  separated  epiphysis  may  become  adherent  to  the 
acetabulum  has  already  been  mentioned.  The  deformities  of  the  pelvis 
as  a  whole  are  almost  identical  with  those  in  tuberculous  coxitis. 

Symptoms. — The  onset  is  usually  sudden.  People  previously  perfectly 
well,  usually  children  or  young  adults  the  picture  of  health,  are  suddenly 
taken  sick,  with  high  fever,  often  with  chills  and  mental  disturb- 
ances. Intense  pain  is  complained  of  in  the  affected  limb,  localized 
in  the  hip  or,  as  in  tuberculous  coxitis,  in  the  knee.  It  is  greatly 
increased  by  pressure  upon  the  trochanter  or  the  sole  of  the  foot,  as 
well  as  by  the  slightest  movements  of  the  limb,  so  that  the  use  of  the 
limb  is  impossible  and  the  patient  is  obliged  to  remain  in  bed  from  the 
first  day.  A  diffuse  swelling,  cedematous  and  boggy,  soon  appears  at 
the  hip,  especially  in  the  gluteal  region,  over  which  the  veins  are  dilated. 
It  is  usually  not  confined  to  the  hip,  but  extends  over  the  entire  thigh 
to  the  knee  or  even  farther  downward.  If  the  pelvic  bones  are  involved, 
swelling  may  appear  within  the  pelvis  at  the  anterior-superior  spine  or 
extend  to  the  symphysis. 

Exceptionally  the  pain  is  slight ;  there  is  a  gradually  increasing  limp, 
the  severe  symptoms  appearing  after  weeks  or  months.  As  emphasized 
by  W.  Miiller,  v.  Bruns,  and  Honsell,  epiphyseal  osteomyelitis  may  occa- 
sionally begin  as  a  polyarthritis,  namely,  with  swelling  in  several  joints, 
as  in  acute  articular  rheumatism,  the  joints  being  affected  simultaneously 


INFLAMMATION  OF  THE  HIP- JOINT.  461 

or  consecutively.  The  process  then  involves  other  epiphyses  beside  that 
of  the  hip.     The  inflammation  subsides  spontaneously  in  most  of  the 

joints,  while  at  the  same  time  severe  inflammation  develops  in  one  of 
them. 

Course. — The  later  course  varies  according  as  the  exudation  perforates 
the  capsule  and  appears  al  the  surface  or  not.  \on-perforation  is  not 
infrequent.  In  the  IOC)  cases  in  the  Tubingen  clinic  there  were  20  of 
this  sort,  3  were  bilateral.  The  severe  constitutional  disturbances  in 
these  cases  lasted  from  three  to  six  weeks,  and  were  followed  slowly 
but  steadily  by  improvement;  the  pain  ceased,  then  the  fever;  the 
swelling  subsided,  and  recovery  followed  in  from  four  to  six  months. 
The  only  results  of  the  disease  are  then  the  changes  in  the  bone  and 
the  functional  disturbance. 

If  perforation  occurs,  the  course  is  more  severe.  The  acute  general 
symptoms  subside  usually  in  from  one  to  three  months,  possibly  partly 
in  connection  with  perforation  of  the  capsule.  Otherwise  the  course  of 
the  disease  is  determined  essentially  by  the  duration  and  intensity  of 
the  discharge.  Before  the  pus  perforates  the  skin  it  usually  burrows 
among  the  gluteals  and  adductors  and  infiltrates  the  soft  parts  extensively, 
the  average  time  before  perforation  occurs  being  six  months.  The 
suppuration  is  maintained  not  only  by  the  joint,  but  also  by  foci  in  the 
bone  with  or  without  sequestra.  The  discharge  is  extremely  protracted, 
and  many  patients  succumb  to  it  who  have  survived  the  acute  stage; 
it  usually  lasts  about  three  years.  Occasionally  the  disease  is  very  acute; 
the  picture  is  then  that  of  a  severe  fulminating  sepsis,  and  death  follows 
in  from  five  to  twelve  days  after  the  onset,  usually  after  an  affection  of 
the  lungs  has  been  added. 

As  mentioned,  in  the  cases  of  non-perforation  recovery  follows  within 
a  year;  in  the  cases  with  discharge  usually  in  from  three  to  four  years 
if  the  patients  do  not  succumb  meanwhile.  Complete  restitution  occurs 
only  in  the  mildest  cases;  usually  a  certain  amount  of  disability  persists 
corresponding  to  the  changes  in  the  bones  and  joint;  it  is  particularly 
in  such  instances,  especially  if  the  continuity  of  the  bone  and  the  joint 
is  preserved,  that  contractures  develop,  the  majority  of  which  are  a 
combination  of  flexion,  adduction,  and  inward  rotation,  or  flexion, 
abduction,  and  outward  rotation.  Numerous  other  combinations  also 
occur.  Where  the  disease  is  bilateral  the  contractures  may  be  symmetrical 
or  not,  or  there  may  be  stiffness  in  one  joint  and  dislocation  in  the  other. 
In  severe  bilateral  adduction  contractures  the  limbs  may  be  crossed. 

Firm  ankylosis  follows  the  contracture  sooner  or  later  in  the  majority 
of  cases.  Shortening  is  usually  less  conspicuous  and  is  evidenced  by  a 
high  position  of  the  trochanter;  the  cause  is  either  atrophy  of  the  upper 
end  of  the  femur,  flexion  of  the  neck,  or  widening  of  the  upper  margin 
of  the  cavity.  Spontaneous  dislocation  is  very  frequent,  in  almost  a 
third  of  the  cases,  and  is  due  either  to  distention  of  the  capsule  in  the 
cases  of  serous  or  catarrhal  coxitis  or  to  destruction  in  the  purulent 
cases.  The  displacement  is  almost  always  backward  and  upward,  and 
usually  occurs  late  in  the  disease  and  upon  slight  provocation.     The 


462  DISEASES  OF  THE  HIP. 

usefulness  of  the  dislocated  limb  is  generally  very  much  impaired,  as 
mobility  is  usually  slight.  Dislocation  forward  is  very  rare;  it  has  been 
seen  as  the  obturator  and  iliopubic  variety,     (v.  Brims  and  Honsell.) 

Separation  of  the  epiphysis,  as  mentioned,  is  very  frequent.  The 
symptoms  vary  greatly;  the  limb  is  rotated  outward  or  inward,  and 
more  often  flexed  than  extended.  The  femur  may  be  displaced  upward 
and  backward  on  the  epiphyseal  fragment  and  the  trochanter  lie  1  \  to 
2\  or  even  4  inches  higher  than  normal.  Albert  and  Blasius  have 
reported  cases  in  which  the  femur  was  displaced  forward  on  the  hori- 
zontal ramus  of  the  pubis.  The  mobility  of  the  limb  varies;  naturally 
when  the  separation  takes  place  it  is  abnormal,  later  there  is  more  or 
less  firm  ankylosis.  Sometimes  the  trochanter  can  be  pushed  up  and 
down  for  a  long  while  afterward;  if  such  cases  are  seen  at  a  late  period, 
they  may  be  mistaken  for  congenital  dislocation  of  the  hip.  As  stated, 
the  fracture  may  not  lie  in  the  epiphyseal  line,  but  in  the  neck;  the 
diagnosis  then  depends  upon  the  .r-ray.  Recurrence  may  take  place 
years  after  recovery.  Of  the  106  cases  in  the  Tubingen  clinic,  15  died; 
in  4  of  these  resection  or  exarticulation  was  performed. 

Diagnosis. — Tuberculous  coxitis,  the  most  important  consideration  in 
the  diagnosis,  is  excluded  by  the  acuteness  of  the  onset.  The  diagnosis 
is  more  difficult  if  the  disease  is  subacute  or  is  seen  at  a  later  period; 
the  appearance  of  the  disease  in  perfectly  healthy  adolescents,  sponta- 
neous dislocation,  separation  of  the  epiphysis,  or  coexistent  osteomyelitis 
in  other  parts  of  the  body,  would  then  be  important.  Further,  a  bac- 
teriological examination  is  of  value,  as  in  all  cases  of  osteomyelitis  the 
pvogenic  cocci  are  present,  chiefly  Staphylococcus  pyogenes  aureus,  rarely 
streptococcus  or  pneumococcus.  The  rr-ray,  particularly  in  older  cases, 
gives  the  diagnosis  with  certainty.  According  to  Bardenheuer  and 
Obalinsky,  in  osteomyelitis  of  the  epiphysis  and  acetabulum  thickening 
can  be  felt  per  rectum  at  the  acetabulum. 

Prognosis. — According  to  v.  Brims  and  Honsell,  the  prognosis  can  be 
summarized  as  follows: 

At  the  onset  the  condition  of  the  patient  is  almost  always  extremely 
serious.  A  decision  during  the  acute  stage  as  to  the  further  course  cannot 
be  given;  in  the  experience  of  some  observers  it  would  appear  that  death 
is  more  frequent  than  recovery.  Later,  after  the  severe  symptoms  have 
subsided,  the  prognosis  is  essentially  better  and  depends  chiefly  upon 
whether  the  coxitis  is  serous  or  catarrhal  (without  perforation)  or  puru- 
lent (with  perforation  of  the  capsule  and  skin).  In  the  former  instance 
the  prognosis  as  to  life  is  favorable;  in  the  latter  death  may  follow  sooner 
or  later  in  the  event  of  general  sepsis  or  pyaemia,  or  from  the  exhaustion 
due  to  protracted  profuse  suppuration  and  amyloid  degeneration  of  the 
viscera.  A  fatal  termination  is  more  likely  if  there  is  separation  of 
•  the  epiphysis  or  osteomyelitic  foci  elsewhere,  especially  if  they  involve 
the  bones  of  the  pelvis.  The  permanent  changes  left  in  the  hip  by  the 
disease  are  very  severe,  although  the  view  exists  that  in  time  the  patients 
are  able  to  work  even  in  the  event  of  separation  of  the  epiphysis  or 
dislocation.      Recurrence  is  occasionally  observed,  as  in  osteomyelitis 


TUBERCULOSIS  OF  THE  HIP-JOINT.  .ji;;; 

in  general,  but  so  rarely  that  it  docs  not  earn-  any  weight  in  the  prog- 
nosis. 

Treatment.  -Although  recovery  has  occasionally  followed  simple 
arthrotomy,  the  author  would  recommend  resection  of  the  hip-joint  as 
the  only  effectual  operation  in  acute  suppuration  of  the  joint,  for  only 
resection  is  able  to  obviate  the  immediate  as  well  as  the  remote  dangers 
of  suppuration.  In  the  Tubingen  clinic  resection  was  performed  in  14 
cases;  only  2  patients  died  at  the  close  of  the  operation,  the  rest  recovered 
and  were  discharged  in  from  two  to  three  months.  The  resulting  defor- 
mities are  treated  according  to  the  rules  to  be  described  later  under  treat- 
ment of  deformities  of  the  hip  in  general. 

TUBERCULOSIS  OF  THE  HIP-JOINT   (COXITIS  TUBERCULOSA). 

Tuberculosis  of  the  hip-joint — coxitis  tuberculosa — may  occur  at  any 
time  of  life,  but  is  chiefly  seen  in  children  between  the  second  and  eigh- 
teenth year,  and  more  particularly  from  the  fifth  to  the  tenth  year. 
Before  the  second  or  after  the  eighteenth  year  the  affection  is  very  rare, 
although  Crocq,  Brodie,  and  Lannelongue  report  coxitis  in  the  first  year, 
and  Morel-Lavalle,  and  later  Marjolin  and  Leon  Labbe,  demonstrated 
tuberculous  inflammation  of  the  hip  in  the  foetus  and  newborn.  These 
are  isolated  observations.  The  disease  may  attack  otherwise  healthy 
persons,  but  is  more  frequently  found  associated  with  tuberculosis 
elsewhere.  According  to  Schmalfuss,  the  hip-joint  is  affected  in  12  per 
cent,  of  all  tuberculous  lesions.  It  stands  third  in  frequency  in  tubercu- 
losis of  the  bones  and  joints.  For  the  general  statistics  we  are  indebted 
to  Watson  Cheyne.  From  his  compilation  of  the  statistics  of  Billroth, 
Menzel,  Jaffe,  and  Schmalfuss,  and  602  personal  cases,  the  vertebrae 
were  found  to  be  affected  in  23  per  cent.,  the  knee-joint  in  16  per  cent., 
and  the  hip-joint  in  15  per  cent,  of  the  cases. 

This  predisposition  of  the  hip-joint  is  referable  to  the  burden  of 
supporting  the  body-weight  and  the  contingent  exposure  to  irritation  and 
injury.  Little  can  be  said  especially  further  in  regard  to  the  etiology  that 
does  not  apply  in  general  to  tuberculosis  elsewhere.  Predisposition, 
heredity,  the  injurious  influences  of  poor  nourishment,  bad  air,  weakening 
illnesses,  etc.,  play  an  important  part.  If  tuberculosis  exists  elsewhere, 
namely,  in  the  lungs,  bronchial  glands,  etc.,  this  focus  is  to  be  regarded 
as  the  primary  source  of  the  hip  disease.  In  rare  cases  the  iliac  bursa, 
which  often  communicates  with  the  hip-joint,  may  transmit  the  tuber- 
culosis from  some  other  part.  Often  the  inflammation  is  preceded  by 
slight  trauma,  so  that  the  latter  should  be  considered  as  a  predisposing 
cause.  In  many  cases  the  author  obtained  a  specific  history  in  the 
parents. 

Pathological  Anatomy. — It  is  very  important  to  determine  the  origin 
of  the  tuberculous  process.  Numerous  investigations  have  shown  that 
the  disease  may  start  in  the  femur,  the  acetabulum,  or  the  synovial 
membrane.     The  femur  and  acetabulum  are  involved  primarily  with 


464 


DISEASES  OF  THE  HIP. 


about  equal  frequency  (Haberen,  Konig,  Marsch,  Lannelongue,  Menard, 
Oilier),  the  synovialis  much  less  frequently  (16  to  17  per  cent,  v.  Volk- 
mann,  Riedel). 

Primary  Tuberculosis  of  the  Synovial  Membrane. — In  this 
variety  the  inflammation  of  the  joint  is  primary,  the  caries  of  the  joint 
secondary.  The  author  believes  with  Konig  that  it  begins  with  a  sero- 
fibrinous exudation  followed  by  tuberculous  degeneration  and  the  forma- 
tion of  spongy  tuberculous  granulations  filling  the  cavity.  The  fibrin 
plays  an  important  part  in  the  further  advance  of  the  disease;  as  Konig 
expresses  it,  the  fibrin  gradually  eats  away  the  cartilage.  The  places  on 
which  the  fibrin  is  deposited  depend  upon  the  attitude  and  movements 
of  the  thigh.  The  result  of  inflammation  of  the  synovialis  varies:  there 
may  be  only  typical  tuberculous  granulations,  or  also  suppuration  and 
caseation  in  the  joint.  The  pus  destroys  the  surface  of  the  cartilage 
more  than  the  fibrin  does.  The  bone  is  thus  exposed  and  subjected  to 
a  process  of  destruction  dependent  essentially  upon  mechanical  factors, 
as  will  be  seen  later.  The  pus  may  work  its  way  through  the  bone  or 
soft  parts  and  perforate  outward. 


Fig.  288. 


Fig.  289. 


Severe  tuberculous  coxitis.  Capsule  greatly  distended 
by  pus.  Resection.  At  a,  in  the  middle  of  the  head,  the 
granulations  have  perforated  the  cartilage.  In  the  neck, 
close  to  the  epiphyseal  cartilage,  lies  a  free  caseous  se- 
questrum the  size  of  a  cherry  pit.  The  abscess  cavity 
perforated  into  and  infected  the  joint  through  the 
fistula  6.     (Krause.) 


Resected  upper  end  of  femur  from  a 
girl  five  years  old.  Natural  size.  Large 
wedge-shaped  subchondral  focus  in  the 
head,  with  demarcation  well  advanced. 
Cartilage  lifted  off  like  a  bulla. 
(Krause.) 


Primary  Tuberculosis  of  the  Bone. — The  focus  may  be  either  in 
the  head,  neck,  trochanter,  or  acetabulum.  Of  381  cases  operated  upon  by 
Konig,  the  focus  in  146  cases  was  in  the  head,  in  187  in  the  acetabulum, 
in  28  in  the  neck,  in  5  in  the  trochanter,  in  5  in  the  shaft,  in  10  in  the 
pelvis  above  the  femur.  In  the  femur  the  primary  focus  is  most  fre- 
quently in  the  epiphysis  of  the  head,  the  part  of  greatest  growth  and 
therefore  with  the  fullest  blood-supply.  According  to  Konig,  the  foci 
in  the  hip  are  as  frequently  single  as  multiple.  The  infection  is  usually 
transmitted  through  the  blood  to  the  bone  and  spreads  thence  in  all 
directions.    The  inflammatory  changes  in  the  bone  at  the  outset  are  not 


rri:i:i;<Ti.<)sis  of  the  hip-joist. 


465 


very  striking  or  characteristic;  there  are  marked  hyperemia  and  the 
beginning  formation  of  tuberculous  granulations.  Later  the  diseased  spot 
is  easily  recognized  as  a  very  vascular,  intensely  red  focus,  usually 
sharply  defined.  With  the  formation  of  a  sequestrum  or  caseation  the 
color  becomes  lighter  and  chalky  The  form  of  the  focus  varies;  it  is 
either  more  or  less  round  (Fig.  288)  or  distinctly  wedge  shape  (Fig.  2S9), 
and  is  in  the  latter  case  to  be  regarded  as  an  embolic  infarct.  The 
focus  may  be  very  small  or  the  size  of  a  pigeon's  egg.  In  the  epiphysis 
a  focus  may  remain  localized  for  a  long  while  without  further  symptoms. 
One  occasionally  meets  with  encapsulated  tuberculous  foci  adventitiously 
in  cutting  through  an  otherwise  healthy  bone.  Such  foci  are  usually 
yellowish-white,  surrounded  by  a  more  or  less  thick  fibrous  capsule,  and 
are  partly  calcified.  They  can  become  completely  enclosed,  but  under 
circumstances  may  be  a  source  of  infection  even  after  years.  Although 
such  foci  may  be  much  more  frequent  than  is  supposed  from  the  fact 
that  they  give  so  few  symptoms,  nevertheless  extension  of  the  focus 
is  to  be  regarded  as  the  usual  result.  The  two  possibilities  in  the  further 
advance  of  the  process  should  be  sharply  distinguished:  perforation 
into  the  joint  and  outside  of  the  joint. 

Fig.  290. 


Fistula  in  the  great  trochanter  running  into  the  neck,  in  a  girl  twelve  years  old.  Joint 
symptoms  of  irritation.  Diseased  bone  chiselled  and  scraped  out.  Four  sequestra  in  the  neck 
surrounded  by  masses  of  granulation  tissue.  Length  of  cavity,  2l/z  inches.  Recovery  with  free 
mobility  of  joint,     (v.  Volkmann.) 


Extra-articular  Perforation. — That  perforation  outside  of  the 
joint  is  more  favorable  and  may  recover  requires  no  explanation.  Even 
in  the  event  of  long-continued  suppuration  and  the  formation  of  sequestra 
these  cases  are  more  favorable  than  the  intra-articular  processes.  What 
it  is  that  determines  the  site  of  perforation  of  the  focus  it  still  unknown; 
not  only  the  foci  lying  close  beneath  the  periosteum  or  developing  in  the 
trochanter  may  perforate  outward,  but  occasionally  also  those  deeply 
situated  in  the  neck  and  head.  A  long  fistula  then  burrows  from  the 
head  through  the  trochanter  to  the  surface.  (Fig.  290.)  The  process  of 
perforation  does  not  meet  with  very  much  resistance;  the  cortex  of  the 
femur  at  the  epiphysis  is  rather  thin;  the  periosteum,  lifted  off  by  the 
Vol.  III.— 30 


466 


DISEASES  OF  THE  HIP. 


Fig.  291. 


pus  like  a  bulla,  is  infected  and  destroyed;  the  overlying  soft  parts  are 
then  easily  perforated.    Such  extra-articular  perforation  from  the  femur 

is  rather  rare,  as  the  larger  part  of 
the  neck  and  head  are  enclosed  by 
the  capsule  so  that  the  numerous 
foci  in  the  head  and  neck  follow  the 
shorter  route  into  the  joint. 

Ixtra-articular  Perforation. — 
If  the  focus  perforates  as  in  the  fore- 
going, the  primary  ostitis  is  followed 
by  secondary  arthritis.  The  com- 
munication may  be  through  one  or 
more  fine  fistulas  or  the  cartilage 
may  be  entirely  lifted  off  and  de- 
stroyed. (Figs.  291  and  292.)  The 
perforating  pus  rarely  finds  an  in- 
tact joint,  for  if  the  process  has  once 
reached  the  outer  coverings  of  the 
joint  it  naturally  irritates  the  ad- 
jacent tissues,  which  cannot  fail  to  react  upon  the  joint.  One  of  the 
first  symptoms  then  is  a  serous  effusion  in  the  joint,  and  the  further 
development  of  the  synovial  tuberculosis  follows  upon  this  the  same  as 


Frontal  section  of  a  resected  head.  Epiphy- 
seal cartilage  of  the  head  and  great  trochanter 
intact.  Greater  part  of  the  head  destroyed 
and  covered  over  with  a  layer  of  granulation 
tissue;  a,  a  cheesy  sequestrum  lying  super- 
ficially in  the  lower  end  of  the  neck,  which 
had  infected  the  joint.     (Krause.) 


Fig.  292. 


riesectio  coxae  dextrse  (natural  size).     Tuberculous  foci  immediately  beneath  the  joint  cartilage, 
which  has  been  lifted  off  like  a  cowl;  6,  sieve-like  perforation  of  the  cartilage,     (v.  Volkmann.) 


if  the  synovialis  were  affected  primarily.     In  very  rare  instances  the 
contiguous  cartilages  are  destroyed  and  bony  adhesions  formed  in  the 


TUBERCULOSIS  OF  THE  II  IP-JO  INT. 


467 


joint  before  the  focus  perforates.  As  a  rule,  however,  the  focus  per- 
forates into  a  still  freely  movable  joint;  every  movement  then  naturally 
spreads  the  infection  so  that  the  delicate  synovialis  is  usually  attacked 
throughout  its  entire  extent.  The  cartilage  may  be  completely  destroyed, 
partly  from  the  focus  in  the  epiphysis,  partly  from  the  secondarily 
affected  synovial  membrane.  If  the  hone  is  then  exposed,  it  is  subjected 
to  the  mechanical  action  of  pressure  and  friction,  which  destroy  it  and 
produce  the  ulcerating  decubitus  of  v.  Volkmann.  The  head  becomes 
smaller  and  flattened,  and  may  be  so  deformed  as  to  be  unrecognizable* 


Fig.  293. 


Frontal  section:     1.  Ilium.     2.  Head  of  femur  containing  a  cheesy  focus,  a. 
4.  Shaft  of  femur  with  cheesy  focus,  b.     (Krause.) 


3    Great  trochanter. 


Separation  of  the  Epiphysis. — If  the  disease  advances  toward  the 
epiphyseal  line  and  not  toward  the  cartilage  of  the  head,  the  epiphysis 
may  be  loosened.  If  the  epiphyseal  cartilage  is  destroyed  rapidly,  the 
separated  head  may  not  become  adherent  to  the  acetabulum,  but  lie 
free  as  a  sequestrum;  the  consequent  irritation  may  occasion  long- 
continued  suppuration.  If  separation  takes  place  slowly,  the  head  may 
become  so  firmly  adherent  to  the  inflamed  synovialis  of  the  acetabulum 
that  they  appear  as  one  piece.  The  head  is  then  preserved  and  receives 
its  nourishment  through  the  adhesions  with  the  acetabulum.  (Fig.  293.) 
Instead  of  loosening  the  epiphysis,  the  process  may  perforate  it  and 
involve  the  shaft  secondarily.  The  spongiosa  will  then  gradually  disap- 
pear and  the  medullary  cavity  become  enlarged  by  the  rarefying  ostitis. 
The  medullary  cavity  presents  a  typical  picture  of  tuberculosis.     The 


468 


DISEASES  OF  THE  HIP. 


rarefaction  can  reduce  the  cortex  to  a  shell  so  compressible  that  the 
contents  of  the  cavity  may  be  squeezed  out  through  any  opening  that 
exists.  With  this  condition  the  possibility  of  spontaneous  fracture  is 
readily  understood. 

The  Acetabulum. — The  acetabulum  may  be  affected  primarily  or 
secondarily;  the  former  applies  generally  to  the  severe  cases.  The 
changes  in  the  bone  and  cartilage  correspond  to  those  in  the  femur.  If 
the  cartilage  is  destroyed,  "ulcerating  decubitus"  may  follow  and  the 

cavity  be  either  deepened,  or,  as 
is  more  common,  the  pressure 
of  the  head  may  gradually  wear 
off  the  upper  posterior  margin  of 
the  acetabulum,  the  cavity  being 
thus  displaced  upward,  the  so- 
called  "wandering"  cavity.  (Fig. 
294.)  It  is  obvious  that  this 
condition  can  be  mistaken  under 
circumstances  for  dislocation.  If 
the  head  lies  upon  the  acetabular 
margin,  one  frequently  finds 
upon  the  former  an  eroded  de- 
pression running  transversely  or 
semicircular  in  shape.  If  the 
suppuration  in  the  joint  is  pro- 
fuse, the  pus  may  perforate 
through  the  floor  of  the  cavity 
into  the  pelvis. 

Dislocation.  —  Dislocation 
may  occur  if  the  head  is  de- 
formed and  flattened  and  the 
cavity  widened.  Corresponding 
to  the  anatomical  relations,  it  is 
usually  the  iliac  form.  (Fig.  295.) 
In  many  instances  it  occurs  sud- 

Wandering  of    the  joint   cavity  in  adult  case  of  denly,  but,   as     a    Tllle,  gradually, 

coxitis.     The  old  cavity  is  separated  from  the  new  \{\^q    ^}^g     C'han°*eS     in     the     bone 

and  larger  cavitv  on  the  outer  surface  of  the  ilium  -p,  e         1  •  1   ■ 

by  a  wall  of  bone.     (Krause.)  Kare  a*5«3  of  pilblC  Or  obturator 

dislocation  have  been  reported 
by  a  few  authors.  Exceptionally  the  dislocation  occurs  very  early,  in 
the  first  weeks  of  the  disease;  Konig  demonstrated  that  this  form, 
occurring  while  the  head  is  still  intact  and  resulting  from  slight  violence, 
is  usually  referable  to  involvement  of  the  bone  of  the  acetabulum  and 
an  exuberant  growth  of  granulations.  Kirmisson  recently  reported  4 
instances  of  sudden  dislocation,  1  of  which  occurred  in  the  second  month, 
and  compared  them  to  the  sudden  dislocation  in  acute  infectious  diseases 
(typhoid,  variola).  Relaxation  of  the  capsule  or  ligaments,  due  to 
effusion  in  the  joint  (Petit),  muscular  traction  (Verneuil),  and  granula- 
tions in  the  joint  cavity,  are  regarded  as  the  predisposing  causes.     The 


ri  i;i:i:<ri.dsis  of  the  uir  JOINT. 


469 


inflammation  or  the  dislocated  femur  can  occasionally  give  rise  to 
proliferation  of  hone  on  the  pelvis.  Flat  deposits  are  also  found  on  the 
femur.    I  Fig.  296.)    'The  growth  may  he  more  or  less  wreath-shaped  or 

like  stalactites  ahont  the  feninr;  it  may  he  so  extensive  as  to  almost 
completely  envelop  the   head    and    require  resection  in  order  to  remove 

the  latter. 

Ahsckssks. — The  abscess  plays  an  important  part  in  the  pathology 
of  coxitis.  As  stated,  it  may  emanate  from  an  osseous  foens  or  the 
synovial  membrane  and  appear  at  numerous  points  ahont  the  hip.  Its 
position  may  correspond  to  its  origin;  abscesses  originating  in  the  medial 

a  Fig.  295.  b 


a,  b.  Spontaneous  iliac  dislocation  following  suppurative  coxitis  and  carious  destruction  of 
the  head  of  the  femur  in  a  child.  Marked  high  position  of  the  dislocated  head  upon  the  ilium. 
Formation  of  a  very  incomplete  and  shallow  new  joint  cavity,     (v.  Volkmann.) 

parts  of  the  joint  may  perforate  on  the  inner  surface  of  the  thigh;  those 
arising  in  the  front  part  of  the  joint  may  perforate  below  the  middle  of 
Poupart's  ligament;  gluteal  abscesses  generally  originate  in  the  posterior 
portion  of  the  joint.  Usually  they  present  on  the  front  and  outer  surface 
close  to  the  tensor  fasciae  latas,  or  on  the  medial  surface  in  the  adductor 
region.  Abscesses  perforating  through  the  acetabulum  into  the  pelvis 
may  appear  in  the  rectum,  bladder,  or  vagina,  or  directly  in  the  perineum. 
The  site  of  perforation  often  does  not  correspond  to  the  focus;  such 
burrowing  abscesses  may  travel  some  distance  so  that  a  probe  introduced 
into  the  fistula  does  not  reach  the  focus. 


470  DISEASES  OF  THE  HIP. 

Arrested  Developmemt. — The  inhibition  of  growth  caused  by  tuber- 
culous coxitis  usually  affects  the  entire  limb.  If  the  epiphyseal  cartilage 
is  destroyed,  the  corresponding  bone  is  retarded  in  growth  on  account 
of  the  premature  synostosis  which  usually  occurs.  In  contrast  to  this 
kind  of  shortening  limited  to  a  single  bone  the  inertia  of  the  entire  limb 
may  be  responsible  for  the  retarded  growth  and  atrophy  of  all  the  bones 
of  the  limb,  the  femur,  tibia,  and  fibula  being  shorter  and  thinner,  and 
the  entire  plantar  surface  of  the  foot  being  smaller  than  that  of  the 
sound  foot,  as  is  easily  demonstrable  by  means  of  charcoal  impressions. 

Changes  in  the  Pelvis. — Hofmeister  has  recently  demonstrated 
convincingly  the  interesting  changes  occurring  in  the  pelvis.  During 
the  painful  period  of  the  disease  and  the  development  of  the  flexion 
attitude,  the  patient  bears  the  weight  of  the  body  almost  entirely  on 

Fig.  296. 


Front  view  of  the  resected  upper  end  of  femur  (natural  size).  Greater  part  of  head  destroyed 
by  caries.  Periosteal  proliferation  of  new  bone  on  the  neck  in  the  form  of  flat  deposits. 
'Krause.) 

the  sound  limb;  the  weight  of  the  flexed  limb  combined  with  the  traction 
and  shortening  of  the  muscles  running  to  the  pelvis  almost  always 
produce  changes  in  the  more  or  less  pliant  and  yielding  bones  of  the 
pelvis,  which  may  be  of  far-reaching  importance.  It  need  only  be 
mentioned  that  the  typical  pelvis  of  hip  disease  may  present  great 
hindrances  to  parturition.  On  the  sound  side  the  pressure  at  the 
hip  forces  the  front  part  of  the  pelvis  backward;  on  the  affected  side 
the  iliopectineal  line  is  widened  out  into  a  large  semicircle,  especially 
near  the  acetabulum.  Above  it  the  ilium  is  directed  more  vertically;  the 
anterior  half  of  the  pelvis  dips  downward  and  is  twisted  laterally  toward 
the  affected  side.  The  tuber  ischii  and  the  anterior-superior  spine  are 
forced  toward  the  cavity  of  the  pelvis  and  the  entire  half  of  the  pelvis 
on  the  affected  side  is  inclined  sharply  downward.  The  pelvic  entrance 
is  obliquelv  ovoid.  (Fig.  297.)  The  muscles  and  soft  parts  about  the 
joint  are  even  more  affected  by  the  inflammation  and  the  inertia  than 
the  bones;  the  muscles  about  the  hip  atrophy;  almost  all  the  soft  parts  in 
front  of  the  joint  undergo  shortening,  partly  cicatricial,  partly  nutritive. 


Tri;i:i;c('Losis  of  the  iiw  .misr. 


471 


The  atrophy  of  the  muscles  <>f  the  limb  corresponds  to  the  duration 
of  the  disease  and  the  consequent  disuse  of  the  entire  limb.  The  blood- 
vessels about  the  joint  occasionally  undergo  secondary  changes.  Lan- 
nelongue  called  attention  to  the  not  infrequent  diminution  in  size  of  the 
femoral  artery  and  its  main  branches,  and  other  authors  have  made 
these  changes  responsible  for  the  trophic  disturbance  in  the  limb  by 
reason  of  the  decreased  blood-supply.  In  very  marasmic  and  cachectic 
patients  there  are  occasionally  obliteration  of  the  femoral  vein  and 
phlegmasia  dolens.  Lannelongue  also  called  attention  to  the  secondary 
changes  in  the  lymphatics  and  glands.  The  inguinal  glands  are  almost 
always  inflamed  and  swollen.  Occasionally  the  lymphatics  are  found 
involved  up  to  the  spinal  column.     Involvement  of  both  hips  simulta- 

I-'ig.  297 


Pelvic  changes  in  coxitis.     (Hofmeister.) 

neously  or  consecutively  is  very  rare;  infection  of  the  second  hip  usually 
follows  weeks  or  months  after  the  first.  Menard  saw  7  cases  in  one 
year.     The  author  has  also  seen  several. 

Symptoms. — The  symptoms  may  be  divided  into  those  of  three 
periods,  the  prodromal  stage  and  first  and  second  stage  of  florescence, 
although  this  division  does  not  apply  to  every  case,  as  one  or  the  other 
of  these  stages  may  be  less  distinct. 

The  first  symptoms  at  the  onset  are  usually  pain  and  the  so-called 
voluntary  limp.  Pain  may  be  the  only  symptom  present  for  some  time 
and  a  neuralgia  of  the  joint  be  suspected.  It  may  occur  either  spon- 
taneously or  after  walking  or  other  exertion.  At  night  the  child  may 
awake  with  a  sudden  cry,  complain  of  pain  in  the  joint,  and  then  fall 


472  DISEASES  OF  THE  HIP. 

asleep.  If  such  an  attack  is  watched,  it  is  seen  that  the  cry  of  pain  is 
because  of  a  sudden  muscular  spasm.  The  pain  is  increased  by  any 
manipulation  forcing  the  head  into  the  cavity,  namely,  pressure  upon 
the  trochanter,  upon  the  knee,  the  sole  of  the  foot,  or  in  Scarpa's  triangle. 
Occasionally  pain  is  elicited  by  pressure  per  rectum  against  the  pelvis 
opposite  the  acetabulum.  The  pain  may  radiate  to  the  knee,  especially 
on  the  inner  side,  and  simulate  an  affection  of  the  knee — in  fact,  it  has 
often  been  provocation  for  considering  resection  of  the  knee-joint.  If 
children  complain  of  pain  in  the  knee,  one  should  always  examine  the 
hip-joint,  as  the  referred  pain  is  due  to  direct  irritation  of  the  nerves 
of  the  hip-joint.  The  intensity  of  the  pain  varies;  at  the  onset  it  may 
be  so  severe  that  any  jarring  or  change  of  position  causes  great  discomfort 
and  confines  the  patient  to  bed;  then  again  it  may  not  appear  until 
later  when  the  focus  perforates  into  the  joint. 

The  voluntary  limp  is  often  the  first  noticeable  symptom  of  the 
disease.  The  patient  drags  the  limb  mechanically  without  being 
conscious  that  he  is  protecting  the  joint.  It  may  be  constant  or  inter- 
mittent; the  latter  is  especially  common  at  the  onset.  Sometimes  the  limp 
is  more  marked  in  the  morning  than  in  the  evening,  sometimes  the  reverse. 
With  these  two  symptoms,  pain  and  the  limp,  only  one  other  is  necessary 
to  make  the  diagnosis  positive;  the  most  gentle  attempts  to  abduct  or 
rotate  the  limb  passively  produce  a  distinct  reflex  contraction  of  the 
hip  muscles.  The  author  regards  this  as  a  very  important  symptom. 
It  is  obtainable  even  though  the  child  is  able  to  walk.  The  muscular 
contraction  gradually  produces  fixation  of  the  hip  in  an  abnormal 
typical  position.  This  marks  the  beginning  of  the  second  stage.  If 
pain,  the  limp,  and  reflex  muscular  contraction  are  present,  the  inguinal 
glands  are  usually  swollen. 

The  second  stage  is  the  period  of  development  of  the  contracture, 
which  latter  may  take  place  in  two  ways;  the  limb  first  becomes  flexed, 
abducted,  and  rotated  outward,  and  later  flexed,  adducted,  and  rotated 
inward,  or  it  may  assume  the  second  position  at  the  outset.  The  first 
position  gives  an  apparent  lengthening.  (Fig.  298.)  Bonnet  refers  this 
lengthening  to  the  distention  of  the  joint  by  effusion  and  granulations, 
the  typical  attitude  of  the  limb  giving  the  greatest  space  in  the  joint  and 
so  diminishing  the  pain.  Konig  conceives  rightly  that  the  position  is  due 
to  the  effort  of  the  patient  to  guard  the  limb  against  the  pain  produced  by 
movements  of  the  joint.  In  walking,  the  weight  of  the  body  is  therefore 
thrown  as  much  as  possible  on  the  other  limb;  consequently  the  latter 
is  adducted.  The  affected  limb  becomes  abducted  involuntarily,  as  it 
were.  In  walking  the  hip  is  flexed  slightly  and  rotated  outward  to  obtain 
the  most  comfortable  position.  The  patient  often  walks  on  his  toes  to 
protect  the  hip.  The  effect  of  flexing,  abducting,  and  rotating  the  hip 
outward  can  be  best  illustrated  on  one's  self. 

The  false  attitude  of  the  limb  is  therefore  assumed  voluntarily  by  the 
patient,  although  unconsciously;  it  can  be  completely  overcome  under 
anaesthesia.  After  a  longer  period,  however,  the  muscles  shrink  and  fix 
the  limb  in  a  pathological  position  which  cannot  be  overcome  under 


TUBERCULOSIS  OF  THE  HIP-JOINT. 


473 


an;esthesia.  This  abnormal  position,  which  may  last  for  months  or  years, 
is  naturally  not  without  influence  upon  the  carriage  of  the  pelvis  and 
the  spine,  the  changes  in  the  pelvis  being  the  most  important.  In  the 
erect  position  with  the  limb  abducted  and  flexed,  to  approximate  the 
foot  to  the  ground  the  pelvis  must  be  inclined  on  the  affected  side, 
the   inclination   being   proportional   to   the   amount  of   abduction   and 


Fig.  298. 


Fig.  299. 


. 


Coxitis  in  the  stage  of  flexion,  abduction, 
and  outward  rotation. 


Coxitis  in  the  stage  of  flexion,  adduction, 
and  inward  rotation. 


flexion.  This  produces  an  apparent  lengthening  of  the  limb,  the  sound 
limb  being  adducted  toward,  and  the  affected  limb  abducted  away  from, 
the  middle  line  of  the  body.  In  the  erect  position  the  distance  from 
the  anterior-superior  spine  to  the  internal  malleolus  will  thus  be  shorter 
on  the  sound  than  on  the  affected  side.  This  leaves  out  of  consideration 
the  cases  in  which  destruction  of  the  head  or  acetabulum  has  produced 
dislocation  and  consequent  variation  in  the  length  of  the  limb,  such  as 


474  DISEASES  OF  THE  HIP. 

may  occur  at  an  early  period.  If  the  patient  goes  about  on  crutches 
or  is  recumbent,  there  is  no  cause  given  for  abducting  the  limb,  so  that 
it  is  only  flexed  and  rotated  outward. 

If  compelled  to  be  recumbent,  the  patient  lies  upon  the  sound  hip, 
with  the  affected  limb  supported  in  flexion  upon  it,  the  position  giving  the 
greatest  comfort  and  protection  against  movement.  The  limb  is  adducted 
and  rotated  inward.  If  this  position  is  maintained,  the  muscles  become 
shortened,  especially  the  adductors.  This  attitude  of  flexion,  adduction, 
and  inward  rotation  usually  takes  place  at  a  later  period  in  the  disease, 
namely,  in  the  so-called  third  stage,  in  contrast  to  the  position  of  flexion, 
abduction,  and  outward  rotation  of  the  second  stage.  (Fig.  299.)  The 
cause  of  these  gradual  changes,  beginning  usually  with  marked  flexion, 
has  been  a  complete  mystery  to  surgeons  for  a  long  while,  as  is  still  shown 
by  many  surgical  articles.  The  explanation,  however,  is  very  simple, 
and  is  the  same  as  given  above:  the  recumbent  position  is  rendered 
more  and  more  necessary  by  the  severe  pain,  the  patient  always  lying 
upon  the  sound  side.  As  the  disease  progresses  the  contracture  in  flexion, 
adduction,  and  inward  rotation  develops  from  the  abduction  attitude 
on  purely  mechanical  grounds.  Occasionally,  however,  the  primary 
abduction  persists,  the  joint  having  become  so  fixed  that  any  change 
of  position  is  impossible.  In  walking,  in  order  to  prevent  painful 
movements  of  the  hip-joint,  the  pelvis  is  lifted  on  the  affected  side  to 
compensate  the  adduction  of  the  thigh,  so  that  there  is  an  apparent 
shortening.  Corresponding  to  the  obliquity  of  the  pelvis  there  is  a 
compensatory  static  scoliosis  and  curvature  of  the  linea  alba.  In  the 
recumbent  position  the  flexion  is  easily  concealed  by  a  compensating 
lordosis.     The  fold  of  the  buttock  is  higher  upon  the  affected  side. 

In  addition  to  the  characteristic  symptoms,  pain,  limp,  and  con- 
tracture, the  inguinal  glands  may  be  swollen  and  tender,  or  may  even 
suppurate  and  perforate.  The  hip  is  sometimes  greatly  enlarged  like  a 
"white  swelling,"  more  marked  if  the  muscles  are  atrophied;  the  entire 
hip  appears  densely  infiltrated,  the  contour  of  the  great  trochanter  is 
obliterated,  the  inguinal  fold  lost.  Palpation  meets  with  firm  resist- 
ance; pressure  is  painful.  In  other  cases  the  swelling  may  be  equally 
extensive  and  fluctuating  if  an  abscess  has  formed,  or  there  may  be  mul- 
tiple abscesses  at  various  points  on  the  hip  and  thigh.  The  usual  site 
is  at  the  inner  border  of  the  tensor  fascia3  latne.  They  may  be  round 
or  elongated,  lobulated  or  hour-glass  shape,  especially  those  forming 
beneath  Poupart's  ligament  with  through-fluctuation  between  the 
abscesses  above  and  below  the  ligament. 

The  temperature  is  rarely  an  indication  of  the  extent  of  the  process 
or  of  suppuration,  as  is  well  known,  in  contrast  to  almost  all  the  other 
infectious  diseases.  It  does  give  information,  however,  in  regard  to 
complications,  namely,  the  involvement  of  other  organs.  Fever  may 
be  absent,  or  of  an  indefinite  remitting  character  for  some  time,  or 
continuous,  varying  between  100.4°  and  102.2°  F.  A  sudden  rise  of  tem- 
perature accompanied  by  severe  pain  in  the  hip-joint  indicates  sudden 
perforation  of  an  osseous  focus  into  the  joint  with  reasonable  certainty. 


TUBERCULOSIS  OF  THE  HIP- JOIST.  475 

Dislocation,  most  frequently  backward,  is  not  an  uncommon  occur- 
rence in  the  later  stage  when  the  process  is  well  advanced.  It  is  not 
unusual  for  the  cases  to  be  seen  for  the  first  time  at  this  stage,  after 

the  abscess  has  perforated  and  sinuses  are  present.  The  shortened  limb 
is  flexed,  adducted,  and  rotated  inward;  the  trochanter  lies  above  Roser- 
Xelaton's  line;  the  remaining  portion  of  the  head  can  he  felt  upon  the 
ilium.  The  normal  shape  of  the  head  is  rarely  preserved  unless  the 
dislocation  has  occurred  early  following  trauma.  Iliac  dislocation 
usually  occurs  if  the  limb  is  adducted;  the  pubic  and  obturator  types 
are  extremely  rare.  (Oilier.)  If  the  cavity  has  "wandered  "  upward  and 
backward,  the  trochanter  above  Roser-Nelaton's  line  projects  sharply 
sideways;  the  head  cannot  be  displaced  upward.  Occasionally  the 
"wandering"  takes  place  directly  upward;  the  head  is  then  checked 
by  the  anterior-superior  spine,  the  symptoms  being  similar  to  those  of 
supracotyloid  dislocation,  namely,  shortening,  outward  rotation,  and 
displacement  outward  of  the  femur;  crepitus  is  usually  present  on 
motion.  If  a  pathological  dislocation  or  "wandering"  of  the  cavity 
exists,  walking  is  usually  facilitated  by  the  development  of  a  compen- 
satory genu  valgum  attitude  of  the  knee. 

Diagnosis. — At  the  onset  the  diagnosis  may  be  difficult,  and  yet  is 
of  the  greatest  importance  at  this  stage  for  a  favorable  prognosis  and 
successful  treatment.  A  limp  existing  for  some  time  and  evidence  of 
a  unilateral  affection  of  the  hip-joint  are  very  suspicious  of  tuberculosis 
if  associated  with  pain  in  the  hip,  either  spontaneous  or  elicited  by 
pressure  against  the  trochanter,  in  Scarpa's  triangle,  or  against  the 
acetabulum  per  rectum.  If  the  pain  is  referred  to  the  knee  and  the  hip 
is  apparently  free,  careful  abduction  of  the  thigh  in  the  recumbent 
position  and  demonstration  of  the  adductor  reflex  are  positive  for  coxitis. 

In  walking,  the  patient  usually  favors  the  affected  limb.  If  told  to 
stand  erect,  the  weight  is  thrown  on  the  sound  limb  and  the  affected 
limb  flexed,  the  patient  often  standing  upon  the  toes  to  prevent  pressure 
upon  the  hip.  The  history,  appearance  of  the  patient,  pallor  of  the 
cheeks,  the  anorexia,  the  disinclination  to  play,  the  restless  sleep  and 
"starting  pains,"  and  the  frequent  demand  of  younger  patients  to  be 
carried  contrary  to  their  usual  habit,  all  point  to  coxitis.  On  the  other 
hand,  a  child  with  coxitis  is  frequently  well  nourished  and  feels  and 
looks  well.  This  is  a  very  important  point  to  be  borne  in  mind,  as  the 
first  mild  symptoms  are  easily  disregarded  in  view  of  the  good  general 
condition.  The  existence  of  abscesses  or  fistulas  facilitates  the  diagnosis. 
Abscesses  in  the  pelvis  are  often  palpable  only  by  relaxing  the  abdom- 
inal muscles  and  exerting  gradual  pressure  in  the  iliac  fossa,  carefully 
pushing  the  intestines  aside.  Digital  examination  per  rectum  in  a  small 
pelvis  may  demonstrate  the  presence  of  an  abscess  or  roughness  of  the 
bone  opposite  the  acetabulum. 

To  demonstrate  a  contracture,  the  patient  is  placed  in  the  dorsal 
position  upon  a  firm,  flat  surface,  the  anterior-superior  spines  marked 
with  ink,  and  the  examination  made  on  both  sides.  A  compensatory 
lordosis  (Fig.  300)  is  recognizable  by  lifting  the  thigh  until  the  patient's 


476 


DISEASES  OF  THE  HIP. 


back  is  flat  upon  the  table.  (Fig.  301.)  The  degree  of  flexion  can  then 
be  determined.  In  very  young  children  in  whom  the  spine  is  very 
flexible  there  is  often  inflexion  of  the  spine  instead  of  a  curvature,  so 
that  the  arch  is  absent.  Abnormal  rotation,  inward  or  outward,  is 
easily  recognized  by  comparing  the  patellae  or  the  feet. 

The  shortening  or  lengthening  and  abduction  or  adduction  are  deter- 
mined by  comparing  the  position  of  the  feet  with  reference  to  the  anterior- 

Fig.  300. 


Flexion  of  the  hip,  lordosis  of  the  lumbar  vertebra?. 

superior  spines;  as  has  been  seen,  great  differences  in  length  can  be 
compensated  by  elevation  or  depression  of  the  pelvis.  With  the  line 
joining  the  anterior-superior  spines  at  a  right  angle  to  the  long  axis 
of  the  body:  if  the  limbs  are  of  equal  length,  there  is  no  abduction  or 
adduction;  if  the  flexed  limb  is  longer,  there  is  an  actual  lengthening 
as  in  dislocation  downward;  if  it  is  shorter,  there  is  an  actual  shortening 
dependent  either  upon  arrested  development,  separation  of  the  epiphysis, 

Fig.  301. 


The  degree  of  flexion  is  shown  when  the  lumbar  spine  is  held  in  contact  with  the  table  by  flexing 

the  other  thigh.      (Whitman.) 


dislocation,  or  "wandering"  of  the  cavity;  in  all  those  conditions  the 
relation  of  the  trochanter  to  Roser-Nelaton's  line  is  important. 

If  the  limbs  are  of  equal  length  and  the  anterior-superior  spine  on  the 
affected  side  is  lower  than  on  the  other,  there  is  an  actual  shortening  If 
the  flexed  limb  is  longer,  there  is  an  apparent  lengthening  due  to  abduc- 
tion (Fig.  302) ;  if  the  limb  is  shorter,  there  is  an  actual  shortening.    If  the 


TUBERCULOSIS  OF  THE  HIP-JOINT.  477 

anterior-superior  spine  on  the  affected  side  is  higher  than  on  the  other, 
there  is  an  actual  lengthening  if  the  Limbs  appear  of  equal  length,  an 
apparent  shortening  or  abduction  of  the  Hexed  limb  if  the  limb  is  shorter; 
and  finally  there  is  an  actual  lengthening  if  the  flexed  limb  is  longer. 
The  degree  of  abduction  or  adduction  is  best  estimated  by  abducting 

Fig.  302.  Fig.  303. 


Apparent  lengthening.    When  the  Apparent  lengthening.     Fixed  abduction  at  45  degrees, 

distorted  limb  is  brought  to  the  me-  When  the  anterior-superior  spines  are  on  the  same  plane. 

dian  line  the  pelvis  is  so  tilted  that  as    in    the    illustration,   the    deformity    is    evident.     (See 

the  abducted  leg  seems  longer.  (See  Fig.  302.)    (Whitman.) 
Fig.  303. )      (Whitman.) 

(Fig.  303)  or  adducting  (Fig.  304)  the  limb  until  the  spines  are  in  the 
same  level,  namely,  until  the  line  joining  them  is  at  a  right  angle  to  the 
long  axis  of  the  body.  Slight  differences  may  be  due  to  superficial 
destruction  of  the  joint-surfaces  or  slight  "wandering"  of  the  cavity. 
The  trochanter  projects  laterally  more  particularly  with  'wandering" 
of  the  cavity  or  dislocation. 


47; 


DISEASES  OF  THE  HIP. 


The  au-ray  should  be  used  if  the  slightest  doubt  exists  as  to  the  nature 
of  the  disturbance  in  the  hip.     As  mentioned,  tuberculous  foci  even  of 

considerable  size  may  exist  for  a  long 
time  without  symptoms;  by  the  .r-ray 
the  size  and  position  of  the  focus  can 
often  be  determined  and  the  proper 
treatment  instituted.  The  earlier  this 
is  done  the  better  the  prognosis.  In 
many  cases  the  destruction  in  the 
joint  can  be  demonstrated  clearly. 
I  _r.  305.)  To  obtain  accurate  infor- 
mation, it  is  necessary  to  .r-ray  both 
hips  ;  in  children  the  cartilages  and 
the  cleft  of  the  joint  are  recognizable 
in  the  sound  hip  as  a  transparent 
semicircular  zone.  On  the  affected 
side  the  line  of  the  joint  is  either 
darkened  or  blurred  (Fig.  306),  or  the 
extent  of  the  destruction  is  recogniz- 
able by  irregular  opacities  or  more  or 
less  distinct  villiform  projections. 

Konig  has  emphasized  properly  that 
small  foci  in  the  bone,  either  on  the 
pelvis  or  in  the  head,  neck,  or  tro- 
chanter, and  slight  abnormalities  show- 
too  indistinctly  in  the  .r-ray,  on  account 
of  the  delicate  structure  of  the  bone 
or  the  relative  thickness  of  the  soft 
parts,  to  give  reliable  information  for 
the  diagnosis  and  prognosis.  It  is 
well  known  that  the  a>iay  pictures  of 
the  hip-joint  are  generally  less  dis- 
tinct than  those  of  most  of  the  other 
,    joints.     Konig  calls  attention  to  the 

Apparent  shortening     ine  adduction  ot  tnp     J  © 

right  thigh  is  made  evident  by  the  invoiun-   fact  that  large  and  small  granulating 

tary  eroding  of  the  legs  when  the  anterior-     fogj    are    easilv  overlooked  Or  mistaken 
superior   spines    are    on    the    same    point.     e  ,  ,*    P  .  .         , 

(Whitm  f°r  abnormal  formations  in  the   me- 

dulla. The  value  of  the  x-ray  picture 
is  unquestionable  if  the  surgeon  is  dealing  with  extensive  destruction, 
marked  changes  in  the  head,  "wandering"  of  the  cavity,  periosteal  pro- 
liferation, separation  of  the  epiphysis,  or  spontaneous  dislocation.  In  a 
few  instances  the  author  distinctly  saw  the  separated  head  lying  in  the 
cavity  and  the  shaft  of  the  femur  displaced  markedly  upward;  in  others 
the  head  had  disappeared  completely,  only  a  slight  thickening  being 
recognizable  on  the  shortened  neck.  Atrophy  of  the  femur  is  also 
shown  clearly,  the  bone  being  smaller  and  more  pervious.  In  one  case, 
following  resection,  the  upper  end  of  the  shaft  was  the  thickness  of  a 
lead-pencil,  although  the  function  was  good.     Even  as  ankylosis  often 


TCHERCULOSIS  OF  the  hip-joist. 


479 


shows  clearly,  so  the  surgeon  can  frequently  study  the  arrested  develop- 
ment of  the  pelvis,  which,  as  mentioned,  may  be  pronounced  in  cases 
of  contracture  of  the  hip-joint  acquired  in  early  life. 

How  careful  one  should  be  in  interpreting  the  above  symptoms  is 
shown  by  the  fact  that  the  limp  and  attitude  of  the  limb  in  adduction 
and  flexion  have  often  been  regarded  as  indicating  coxitis,  whereas  in 
reality  quite  another  lesion  existed.     Menard  recently  reported  a  case 

Fig.  305. 


Early  stage  of  disease  of  the  left  hip-joint  (to  the  right  in  the  picture)  of  the  synovial  type, 
showing  irregularity  in  the  shape  of  the  acetabulum.     (Whitman.; 


sent  to  the  hospital  with  the  diagnosis  of  coxitis  in  which,  after  being 
under  observation  for  three  months,  appendicitis  was  established. 

Differential  Diagnosis. — Although  the  symptoms  at  first  glance  are 
obviously  characteristic  of  coxitis,  one  should  never  omit  to  examine  the 
entire  body  carefully.  A  number  of  diseases  which  must  be  excluded 
give  a  similar  picture,  namely,  growth-pains,  arthritis  deformans, 
fracture  of  the  neck,  traumatic  separation  of  the  epiphysis,  congenital 


480 


DISEASES  OF  THE  HIP. 


dislocation,  traumatic  dislocation,  arrested  development  (especially  after 
infantile  paralysis),  coxa  vara,  hysteria,  neuralgia,  monarticular  rheu- 
matism, acute  and  chronic  synovitis,  tumors  of  the  bursa?,  spondylitis, 
echinococcus,  gonorrhoea,  syphilis  and  other  infectious  diseases,  osteo- 
myelitis, malignant  neoplasms. 

Pains  due  to  growth  may  cause  a  slight  limp  in  one  limb,  are  usually 
located  in  the  shaft,  but  may  resemble  joint-pains  and  be  accompanied 

Fig.  306. 


Advanced   disease,   showing   wandering  of    acetabulum    and  the   obliquity  of    the  pelvis  due  to 
adduction.     Actual  shortening  one  inch,  apparent  shortening  three  inches.   (Whitman.) 


by  slight  elevations  of  temperature.     They  soon  disappear  with  rest  in 
bed  and  are  rarely  elicited  by  forced  movements. 

Arthritis  deformans  may  produce  changes  in  the  joint  giving  several 
symptoms  common  to  tuberculous  coxitis,  but  it  is  extremely  rare  in  child- 
hood and  then  follows  trauma.  The  thickening  in  the  joint  is  so  pro- 
nounced that  confusion  is  hardly  possible.  The  course  is  more  regular 
and  more  chronic,  although  there  may  be  slight  exacerbations.  Eleva- 
tions of  temperature  always  speak  for  tuberculous  coxitis. 


TUBERCULOSIS  OF  THE  HIP  JOINT.  481 

Fracture  is  excluded  by  the  history,  the  patient  beingabout  n|>  to  the 
time  of  injury  without  pain  in  the  hip,  the  violence  being  sufficient  to 
explain  a  fracture  or  separation  of  the  epiphysis.  On  the  other  hand 
if  before  the  trauma,  which  is  held  responsible  for  the  affection  of  the 
hip,  the  patient  had  complained  of  trouble  in  the  hip  in  proportion  to 
which  the  injury  was  slight,  and  tuberculosis  is  found  in  the  other 
organs,  or  there  is  a  tuberculous  heredity,  and  the  pains  in  the  hip 
appear  several  weeks  after  the  injury,  then  there  is  every  reason  to 
suspect  tuberculous  coxitis. 

Congenital  dislocation  may  be  thought  of  if  the  coxitis  has  produced 
a  dislocation,  but  in  the  congenital  form  there  is  no  pain  during  passive 
motion  in  contrast  to  the  fixation  due  to  the  reflex  muscular  contraction 
in  coxitis.  In  numerous  instances,  however,  a  careful  review  of  the 
history  has  been  necessary  to  establish  as  to  whether  or  not  the  limp 
existed  previously  with  pain  and  contractures  and  abscesses.  Paralytic 
dislocation  takes  place  naturally  after  the  paralysis.  Traumatic  dislo- 
cation is  the  direct  result  of  great  violence,  so  that  there  is  no  reason 
to  think  of  coxitis  unless  the  hip  was  previously  affected. 

A  limp  may  be  due  to  shortening  in  one  of  the  bones  of  the  limb; 
the  bone  affected  is  determined  by  accurate  measurement.  If  it  is  the 
femur,  the  examination  also  gives  evidence  as  to  pain,  mobility,  and 
crepitus  in  the  joint,  and  whether  the  cause  of  the  shortening  is  in  the 
joint  or  in  the  shaft. 

Coxa  vara  and  downward  inflexion  of  the  neck  are  to  be  thought  of 
if  the  shortening  is  in  the  articular  portion  of  the  femur,  and  if,  in 
addition  to  the  shortening,  which  may  be  even  3  inches,  the  limb  is 
adducted  and  rotated  outward.  The  extended  position  is  common, 
although  flexion  is  often  reported.  Adduction  can  usually  be  carried 
out  easily  and  without  pain;  abduction  and  inwTard  rotation  are  limited. 
The  differential  diagnosis  may  be  very  difficult,  however,  if  the  inflexion 
of  the  neck  is  due  to  an  inflammation  of  the  hip-joint  without  suppura- 
tion, and  then  requires  the  support  of  a  careful  history,  regard  for  the 
general  condition,  and  the  .r-ray. 

Neuralgic  pains  in  the  hip-joint  are  often  difficult  to  distinguish  from 
those  of  coxitis,  especially  if  the  prodromal  stage  is  protracted.  Brodie, 
Stromeyer,  and  Esmarch  have  called  special  attention  to  hysterical 
joint;  it  occurs  usually  but  not  exclusively  in  females.  The  hip  may 
be  flexed  and  rotated  inward,  there  may  be  variations  of  temperature, 
but  it  is  usually  possible  to  find  a  cause  for  the  hysteria  (pelvic  trouble 
or  other  nervous  disturbances)  or  verify  the  free  mobility  of  the  joint 
by  diverting  and  fixing  the  attention  of  the  patient  or  examining  under 
anaesthesia.  The  .r-ray  is  also  conclusive.  The  pain  usually  wanders. 
The  result  of  the  treatment  employed  on  the  supposition  of  a  joint- 
neuralgia  (massage,  outdoor  exercise,  ice-bag,  compresses)  clears  up  the 
diagnosis. 

Rheumatism,  monarticular,  in  the  hip-joint  is  usually  preceded  by 
repeated  attacks,  is  accompanied  by  friction-sounds  in  the  joint  at  an 
early  period,  rarely  causes  so  much  stiffness  as  tuberculosis,  and  is  more 
Vol.  Ill— 31* 


482  DISEASES  OF  THE  HIP. 

painful  under  unfavorable  atmospheric  conditions.  It  is  improved  by 
the  exhibition  of  salicylic  acid.  With  polyarticular  rheumatism  confusion 
is  hardly  possible 

Chronic  synovitis  is  always  without  swelling  of  the  synovialis.  Evi- 
dence of  tuberculous  foci  in  other  parts  of  the  body  would  aid  the 
diagnosis  of  coxitis  in  doubtful  cases.  Acute  synovitis  may  give  the 
same  symptoms  as  acute  tuberculosis  of  the  joint,  for  example,  after 
sudden  perforation  of  an  osseous  focus.  Trauma  often  immediately 
precedes  both  conditions,  and  the  synovialis  is  usually  much  swollen. 
In  the  absence  of  a  history  of  previous  limping,  weakness,  etc.,  puncture 
may  be  necessary  in  doubtful  cases. 

Tumors  of  the  bursa:*  of  the  hip,  especially  inflammation  of  the  iliac 
bursa,  may  produce  the  same  anomalous  position  of  the  thigh,  namely, 
abduction,  outward  rotation,  and  flexion,  as  coxitis.  Abscesses  of  the 
bursa?  may  present  at  any  point  on  the  hip  or  thigh  and  wander  as  in 
tuberculosis.  Pain  radiating  to  the  knee  is  common  to  both  affections. 
In  bursitis  abduction,  outward  rotation,  and  flexion  may  be  effected 
without  pain,  whereas  movements  in  the  opposite  direction  can  only  be 
carried  out  under  anaesthesia  on  account  of  the  firm  reflex  muscular 
contraction.  The  iliac  bursa  occasionally  communicates  with  the  hip- 
joint  so  that  inflammation  of  the  former  may  be  transmitted  to  the 
latter.  Abscesses  anywhere  in  the  pelvis  easily  perforate  into  the  bursa 
and  from  there  into  the  joint. 

Spondylitis  is  always  to  be  thought  of  in  connection  with  such 
abscesses.  The  author  can  only  recommend  urgently  that  the  spinal 
column  be  examined  carefully  in  every  ease  in  which  coxitis  is  not  clear; 
abscesses  from  either  direction  may  appear  at  any  point  in  the  pelvis 
or  on  the  thigh;  in  spondylitis  a  reflex  spasm  of  the  iliopsoas  may  produce 
an  anomalous  position  of  the  thigh  as  in  coxitis.  A  superficial  examina- 
tion may  therefore  have  serious  consequences.  Under  anaesthesia  the 
mobility  of  the  hip  can  be  ascertained  and  the  conditions  verified  by  the 
x-ray. 

Echinococcus  will  be  diagnosed  from  the  history  and  aspiration. 

Gonorrhoea!  inflammation  of  the  hip  is  not  uncommon,  and  often 
produces  complete  bony  ankylosis,  in  dired  contrast  to  coxitis,  in  which 
bony  adhesions  between  the  articular  surfaces  is  extremely  rare.  Evi- 
dence elsewhere  of  gonorrhoea  confirms  the  diagnosis. 

Syphilis  may  also  produce  bony  ankylosis,  and  will  be  determined 
by  the  history,  evidence  of  a  primary  lesion,  and  the  effect  of  specific 
treatment.  Special  attention  is  called  to  the  extremely  severe  pain  of 
syphilitic  coxitis.  One  of  the  author's  female  patients  cried  out  night 
and  day  on  account  of  the  pain.  She  was  not  a  nervous  woman,  but 
the  least  contact  of  the  bedclothing  caused  intense  agony.  The  diag- 
nosis of  the  joint-affections  following  the  infectious  diseases,  such  as 
measles,  scarlet  fever,  typhoid,  variola,  puerperal  fever,  will  depend 
upon  the  history.  These  are  usually  severe  suppurations,  not  infre- 
quently causing  spontaneous  dislocation  and  ankylosis. 

Osteomyelitis,  especially  of  the  epiphysis,  under  circumstances  can 


TUBERCULOSIS  OF  THE  HIP-JOINT.  483 

be  very  difficult  to  distinguish  from  tuberculous  coxitis,  as  they  both  give 
the  same  symptoms  except  that  the  process  in  osteomyelitis  is  usually 
more  rapid.  High  temperature  and  simultaneous  involvement  of  several 
bones  speak  for  osteomyelitis.  If  fistulas  exist,  the  microscopical  exam- 
ination of  the  scrapings  may  give  information,  although  mixed  infection 
very  frequently  makes  the  differentiation  difficult,  as  noted  by  P.  v.  Bruns. 

Malignant  tumors— sarcoma  and  carcinoma — may  give  the  symptoms 
of  coxitis.  They  are  more  common  in  advanced  life,  whereas  tubercu- 
losis is  seen  chiefly  in  youth.  A  primary  neoplasm  in  the  hip-joint  is 
especially  confusing;  on  the  other  hand,  if  there  is  a  carcinoma  of  the 
breast  or  sarcoma  of  the  maxilla,  or  malignant  neoplasms  elsewhere, 
one  naturally  thinks  of  secondary  involvement.  Periosteal  sarcoma  of 
the  trochanter  usually  forms  a  larger  tumor  than  the  swelling  of  coxitis, 
but  may  give  fluctuation  if  softening  occurs.  The  overlying  skin  is 
usually  more  brownish  and  the  veins  more  dilated  than  in  tuberculosis, 
and  the  inguinal  gland  more  swollen.  In  sarcoma  the  tumor  spreads. 
Myelogenous  sarcoma  occasionally  produces  the  same  pathological  posi- 
tion of  the  limb  as  coxitis;  Englisch  reports  several  cases  in  which  the 
limb  was  first  abducted,  then  adducted;  in  others  there  were  dislocation 
and  fracture  of  the  destroyed  part  of  the  joint.  If  the  neoplasm  is  very 
large,  it  may  give  pulsation,  vascular  murmurs,  and  parchment  crack- 
ling- 

In  either  carcinoma  or  sarcoma  exploratory  incision  is  indicated  if 

all  other  evidence  is  exhausted.  Carcinoma  of  the  neck  of  the  femur 
is  not  very  rare,  the  swelling  about  the  joint  being  insignificant,  while 
the  inguinal  glands  are  greatly  enlarged  and  the  interior  of  the  bone  is 
gradually  absorbed.  Motion  in  the  joint  is  usually  possible  for  a  long 
time  actively  and  passively  until  the  destruction  has  advanced  so  far 
that  fracture  or  dislocation  occurs,  usually  from  slight  trauma. 

Prognosis. — The  serious  character  of  a  tuberculous  arthritis  should 
always  be  kept  clearly  in  mind.  Even  in  apparently  mild  cases  one 
should  be  careful  not  to  give  a  favorable  prognosis  unconditionally  as 
encapsulated  foci  may  be  the  starting-point  of  new  inflammation  even 
after  years.  Nevertheless  a  tuberculous  inflammation  of  the  hip-joint 
gives  a  better  prospect  of  recovery  and  of  being  limited  to'  the  focus 
than  tuberculosis  of  the  viscera.  The  general  condition  of  the  patient 
is  significant.  In  cachectic  children  with  extensive  tuberculosis  the 
prognosis  of  coxitis  is  obvious;  likewise  with  an  inherited  tendency  it 
is  always  possible  that  the  tuberculosis  may  develop  in  other  places 
and  death  result  from  general  tuberculosis  or  involvement  of  the  lungs 
or  meninges. 

P.  v.  Brims  found  that  in  spite  of  local  recovery,  6  per  cent,  of  the 
patients  died  of  phthisis  in  the  first  decade,  9  per  cent,  in  the  second 
decade,  and  7  per  cent,  in  the  twentieth  to  the  fortieth  year.  Severe  sup- 
puration always  jeopardizes  life,  especially  on  account  of  the  amyloid 
degeneration  of  the  viscera,  the  kidneys  being  most  frequently  involved. 
A  high-grade  albuminuria  usually  means  amyloid  degeneration  of  the 
kidneys.    In  the  author's  experience  the  average  duration  of  life  in  the 


484  DISEASES  OF  THE  HIP. 

non-suppurative  cases  is  three  and  one-half  years,  in  those  with  suppu- 
ration about  five  years.  The  largest  number  of  recoveries  occurs  up  to 
the  fifth  year,  the  number  decreasing  slightly  to  the  twentieth  year  and 
then  rapidly.  Recovery  after  the  fortieth  year  is  almost  impossible, 
especially  if  there  is  suppuration,  v.  Brims  gives  50  per  cent,  of  recovery 
in  general. 

Cold  abscesses  perforating  on  the  hip  or  thigh  may  favorably  influence 
the  course  by  giving  drainage  to  the  pus.  Sequestra  in  the  bones  of 
the  joint  may  occasion  long-continued  suppuration,  exhaustion,  and 
cachexia.  Cases  of  spontaneous  absorption  of  the  abscess  are  reported, 
especially  in  youth.  Recovery  frequently  follows  the  injection  of  iodo- 
form-glycerin.  Perforation  into  any  of  the  pelvic  organs  can  always  be 
serious.  Putrefaction  of  the  pus  prevents  the  formation  of  a  limiting 
wall  of  cicatricial  tissue  and  the  fixation  of  the  joint.  In  the  non- 
suppurative form,  even  after  considerable  destruction  of  the  joint, 
cicatricial  tissue  may  solidify  the  joint;  bony  ankylosis  is  very  rare. 

Destruction  of  the  bone  is  always  followed  by  more  or  less  functional 
disturbance.  If  the  head  is  absorbed,  its  function  may  be  assumed 
partially  by  the  neck;  if  the  destruction  is  more  extensive  and  involves 
the  epiphyseal  cartilage,  there  may  be  dislocation,  wandering  of  the 
cavity,  separation  of  the  epiphysis,  arrested  development  of  the  femur 
or  of  the  entire  limb.  Reduction  of  a  dislocation  is  followed  immediately 
by  luxation  unless  the  destruction  of  the  femur  or  pelvis  is  slight,  and 
except  in  the  case  of  sudden  dislocation  at  the  beginning  of  the  disease, 
in  which  by  careful  treatment  the  prognosis  is  favorable. 

Conservative  treatment  to-day  holds  out  greater  hope  of  preserving 
the  joint  and  bringing  about  a  recovery  even  in  severe  cases,  whereas 
formerly  operation  was  almost  always  resorted  to  and  all  diseased  and 
destroyed  tissue  removed,  naturally  with  greater  functional  loss.  The 
author's  experience  at  least  attests  to  the  good  results  of  conservative 
treatment;  the  earlier  the  rational  procedure  is  instituted  the  more 
favorable  the  outcome.  At  a  later  stage  operation  may  be  the  only 
means  of  saving  life.  The  prognosis  is  favorable  in  direct  relation  to 
the  youth  of  the  patient;  in  children  the  disease  is  more  apt  to  be 
limited  than  in  older  people.  Diminution  of  the  pain  and  the  limp  and 
greater  mobility  of  the  joint  are  the  favorable  signs  of  convalescence. 

The  pathological  fixation  in  flexion,  rotation,  abduction,  or  adduction 
can  usually  be  corrected,  and  merely  the  shortening  left  to  be  compen- 
sated mechanically.  The  adaptability  of  the  body  to  the  deformity  is 
astonishing;  even  marked  contractures  are  often  compensated  by  eleva- 
tion or  depression  of  the  pelvis,  lordosis,  or  scoliosis.  The  shortening 
is  the  chief  source  of  the  functional  disturbance.  In  the  author's 
experience,  and  according  to  the  various  statistics,  recovery  without 
shortening  belongs  to  the  greatest  rarities.  Of  106  cases  cited  by  v. 
Brims  and  ^\Tagner,  only  4  recovered  without  shortening,  and  these 
were  without  suppuration.  Actual  shortening  is  due  partly  to  arrested 
development  of  the  thigh,  partly  to  upward  displacement  of  the  tro- 
chanter above   Roser-Nelaton's  line,  the   latter  being  the  cause  in  80 


TUBERCULOSIS  OF  THE  HIP  JOINT.  485 

per  cent.  The  average  shortening  up  to  the  fifth  year  without  sup- 
puration is  1,!  inches,  with  suppuration  2\  inches;  in  coxitis  developing 
in  later  life,  1  ',  to  2  inches. 

According  to  v.  Bruns,  death  occurs  in  40  per  cent,  of  the  cases  after 
an  average  duration  of  three  years,  and  chiefly  from  tuberculosis  of  the 
lungs  and  meninges,  and  general  miliary  tuberculosis,  meningitis  being 
the  cause  in  nearly  a  third  of  the  children  up  to  the  fifteenth  year. 
Recovery  occurs  in  77  per  cent,  of  the  cases  without  suppuration,  in 
42  per  cent,  with  suppuration,  suppuration  more  than  doubling  the 
mortality.  Recovery  in  the  first  decade  is  represented  by  65  per  cent., 
in  the  second  decade  by  56  per  cent.,  in  the  third  and  fourth  by  28  per 
cent.,  and  in  the  fifth  by  (i  per  cent.  After  the  twentieth  year  recovery 
is  rare,  especially  in  the  fungous  purulent  type. 

Billroth  saw  11  instances  of  complete  recovery,  and  IS  with  functional 
impairment  of  the  joint,  in  54  cases.  Among  63  cases  Jacobsen  saw 
17  recoveries  and  40  deaths.  Of  27  patients  ranging  from  one  to  fifteen 
years,  seen  by  Ilenle  in  the  Breslau  clinic,  20  were  treated  successfully. 
Of  Marsch's  139  cases,  48  died,  54  recovered,  9  remained  unhealed, 
and  22  were  lost  sight  of.  Of  Konig's  410  cases,  seen  during  a  period 
of  twenty  years  and  followed  after  being  discharged,  168  died,  248 
recovered,  140  of  the  latter  being  treated  conservatively,  114  by  opera- 
tion. 

Treatment. — In  the  first  stage  three  things  are  essential:  general  diet, 
prophylaxis,  and  the  local  treatment.  As  in  any  tuberculous  arthritis, 
rest  is  of  first  importance,  more  so  in  the  lower  extremity  than  in  the 
upper.  Its  value  is  attested  by  the  mildness  of  the  inflammation  in  the 
second  joint  in  the  cases  of  bilateral  coxitis  which  are  kept  in  bed.  Fresh 
air  is  also  of  great  benefit,  although  one  should  not  sacrifice  the  resting 
of  the  limb  to  obtain  it.  Experience  has  taught  that  well-to-do  patients, 
not  obliged  to  live  in  small  rooms  in  a  narrow  street,  make  a  much 
better  recovery  than  the  poor.  Sea  air  is  especially  beneficial;  it  is  there- 
fore a  great  help  to  such  poor  patients  if  they  can  enjoy  the  sea  air  for 
a  time  in  the  summer  outing  of  some  Children's  Aid  Society  or  other 
charity  organization.  Mountain  air  is  also  good.  Also  treatment  in 
a  well-conducted  salt-water  bath.  The  diet  should  consist  of  nutritious, 
easily  digested  food. 

Inunction  with  green  soap,  as  first  recommended  by  Kapesser  and 
Kollman,  has  always  proved  serviceable  in  the  author's  experience;  in 
the  abdominal  position  the  back  and  both  limbs  are  anointed  two  or 
three  times  a  week  with  a  good  soft  soap  (sapo  kalinus  Du  Yernoy 
[Stuttgart]),  as  in  mercurial  inunction,  and  removed  in  one-half  hour 
with  a  sponge.  The  treatment  should  be  continued  for  several  months. 
The  result  is  often  surprising;  swollen  glands  diminish,  the  appetite  and 
general  strength  increase,  even  old  fistulas  may  close  rapidly.  Embro- 
cations of  tincture  of  iodine  or  mercurial  soap  have  been  proposed, 
also  application  of  an  ice-bag  or  Priessnitz  compress  (cold,  wet  com- 
press). Albert's  thermopuncture,  formerly  approved  and  recommended, 
is  little  used  at  present. 


486  DISEASES  OF  THE  HIP. 

Local  Treatment. — Aside  from  the  general  treatment  and  the  use 
of  drugs,  the  local  treatment  is  the  most  important  factor  in  the  entire 
management  of  tuberculous  coxitis.  The  advantages  of  extension  are 
numerous:  Recovery  is  more  rapid,  the  pain  is  diminished,  and  fixation 
in  a  pathological  position  is  prevented.  Fixation  in  slight  abduction 
and  flexion  is  the  least  troublesome,  gives  the  patient  the  least  discomfort 
in  sitting,  and  most  effectually  compensates  any  shortening.  The  favor- 
able influence  of  extension  upon  the  recovery  is  due  to  the  affected  articu- 
lar surfaces  being  held  apart;  there  is  thereby  less  tendency  to  suppu- 
ration, and  the  compression  thus  made  by  the  capsule  and  ligaments 
being  put  on  the  stretch  aids  the  resorption  of  the  joint-contents.  The 
swelling  often  decreases  visibly.  That  the  joint-surfaces  are  drawn 
apart  by  extension  is  shown  in  frozen  specimens  made  on  the  cadaver; 
a  separation  of  If  inches  has  been  seen.  (Konig,  Bradford.)  The 
reciprocal  irritation  of  the  joint-surfaces  being  stopped,  the  painful  mus- 
cular spasms,  which  so  frequently  disturb  the  child  during  sleep,  cease. 
The  spastic  contraction  of  the  muscles  gradually  relaxes  to  normal.  In 
children  the  weight  to  be  effective  should  be  from  25  to  30  pounds; 
in  adults  40  pounds  or  more,  being  increased  until  the  pain  ceases.  Even 
children  sometimes  notice  the  comfort  produced  by  the  extension  and 
beg  for  more. 

If  there  is  no  anomalous  position,  extension  prevents  it;  if  present, 
it  corrects  it.  In  the  absence  of  any  anomalous  position  an  adhesive- 
plaster  extension  splint  is  applied,  as  described  under  fracture  of  the 
neck,  or  a  laced  legging  (Gamasche)  upon  which  traction  can  be 
made.  Counterextension  is  maintained  by  elevating  the  buttocks 
or  by  an  elastic  perineal  band  attached  at  the  head  of  the  bed  and 
weighted.  If  the  limb  is  abducted — that  is,  apparently  lengthened — 
the  extension  should  overcome  and  not  increase  the  deformity,  as  even 
by  simple  extension  the  pelvis  is  drawn  down  on  the  affected  side  and 
the  limb  thus  abducted.  This  should  be  prevented  by  appropriate 
counterextension;  it  may  be  advisable  to  apply  extension  to  the  other 
limb.  Adduction  is  overcome  by  simple  extension  or  counterextension 
on  the  sound  side. 

Portable  Apparatus. — A  very  important  part  of  the  action  of  extension 
is  the  fixation  of  the  diseased  joint,  yet  unfortunately  this  fixation  is 
not  complete,  independent  of  the  amount  of  weight  applied.  The 
portable  apparatus  more  nearly  fulfils  the  requirements  of  immobilization 
essential  to  recovery,  and  has  the  additional  advantage  of  allowing  the 
patient  to  be  about  and  in  the  open  air.  Among  the  apparatus  used 
at  the  present  time,  disregarding  the  obsolete  forms,  should  be  mentioned 
the  American  long  traction  hip  splint,  not  only  because  the  ambulant 
treatment  of  coxitis  was  first  inaugurated  by  the  efforts  of  American 
colleagues  and  has  found  its  widest  application  in  America,  but  also 
because  the  description  of  this  splint  best  defines  the  requirements  of 
a  rational  apparatus.  This  splint,  first  introduced  by  Davis,  Sayre,  and 
Bauer,  has  many  modifications  at  the  present  time;  Fig.  307  shows  those 
of  Taylor  and  Shaffer.     The  splint  is  held  firmly  by  a  pelvic  brace, 


miERCULOSIS  OF  THE  HIP-JOINT. 


487 


extension  being  made  by  means  of  adhesive-plaster  strips  applied  to 
the  leg  and  attached  to  a  foot-pieee  which  can  be  screwed  up  or  flown. 
These  American  splints  appear  to  the  author  to  fulfil  only  partially  the 
above  requirements;  they  overcome  the  reflex  spasm  of  the  muscle 
favorably,  but,  on  the  other  hand,  do  not  give  complete  fixation  as 
shown  by  Lovett's  experiments.  At  each  step  there  is  alternating  pressure 
and  traction — " push-and-pull  action" — upon  the  joint.     Nevertheless 

Fig.  307. 


Long  traction  hip  splints.     (After  Taylor  and  Shaffer.) 

the  numerous  statistics  of  Shaffer  and  Lovett  show  that  the  great  majority 
of  cases  are  cured  by  the  favorable  action  of  the  splint,  although  the  final 
result  is  compromised  very  often  by  the  limb  becoming  fixed  in  a  false 
position,  by  deformities  of  the  knee-joint,  or  the  development  of  a  pes 
equinus.  The  undesirable  results  produced  by  the  splints  constructed 
according  to  Taylor's  principles  are  referable  to  the  incomplete  fixation 
of  the  hip-joint. 


488 


DISEASES  OF  THE  HIP. 


These  drawbacks  can  be  avoided  if  the  limb  can  be  extended  con- 
tinuously in  the  proper  position  and  the  hip-joint  immobilized  and 
exempted  from  the  pressure  of  the  body-weight.  Successful  attempts 
have  been  made  in  this  direction.    The  apparatus  of  Wallace  Blanchard, 

Stillmann,    Phelps,   Lovett,    and    Dane 
Fig.  308.  were  the  first  to  be  constructed  to  this 

end.  Phelps  added  traction  in  the  direc- 
tion of  the  neck.  Lovett  combined  the 
Thomas  splint  with  a  foot-piece  after 
the  principle  of  Taylor.  Dane's  new 
splint,  similar  to  the  one  of  P.  v.  Brims 

Fig.  30; >. 


Hessing's  apparatus  for  coxitis. 


Celluloid  sheath  apparatus.     (After  Lorenz.) 


widely  used  in  Germany,  and  to  be  described  later  under  fracture  of 
the  shaft,  is  said  to  be  very  serviceable. 

In  contrast  to  the  American  splints  should  be  mentioned  the  German 
splints,  especially  those  of  v.  Bruns,  v.  Volkmann,  and  Liermann.  Hess- 
ing's  is  the  best  of  the  German  apparatus;  it  is  almost  perfect  in  its 


miEUcl-LOSls  OF  THE  II1I'  JOINT. 


489 


action,  and  therefore  cannot  be  recommended  too  highly.  The  author 
uses  it  almost  exclusively  in  his  better  practice  It  consists  of  a  sheath 
splint  modelled  to  the  limb  and  attached  to  a  well-fitting  pelvic  brace. 
The  latter  consists  of  two  detachable  halves  accurately  shaped  to  the 
pelvis.  '1  "he  joint  between  the  pelvic  brace  and  the  sheath  can  be 
adjusted  and  locked.  On  the  side  of  the  apparatus  the  author  has 
added  a  firm  iron  strip  to  hold  the  limb  abducted  at  any  angle  desir- 
able, and  in  front  a  reinforcing  strip  of  iron  curved  from  the  side-piece 
to  the  front  part  of  the  pelvic  brace.  (Fig.  308. )  With  this  apparatus  the 
hip-joint  can  be  immobilized  absolutely,  the  other  joints  remaining  free. 


Fig.  310. 


Fig.  311. 


Fig.  312. 


Lorenz'  plaster-of-Paris  splint. 


If  the  pain  in  the  joint  has  entirely  ceased  and  the  surgeon  can  assume 
that  recovery  is  complete,  slight  mobility  in  the  joint  may  be  allowed 
by  loosening  the  screws.  The  apparatus  is  wTorn  for  two  or  three  years, 
being  so  made  that  it  can  be  lengthened  with  the  growth  of  the  child. 
Unfortunately  its  construction  requires  skilful  workmanship. 

Fortunately  for  poor  patients,  the  surgeon  is  able  to  give  them  the 
benefit  of  the  ambulant  treatment  with  less  expensive  apparatus. 
Heusner  constructed  a  simple  apparatus  of  iron  strips  padded  with 
felt.  Lorenz  makes  the  sheaths  out  of  celluloid  instead  of  leather.  (Fig. 
309.)  Port  makes  a  plaster  cast  of  the  pelvis  and  limb,  and  on  it  shapes 
a  sheath  apparatus  out  of  strips  of  cellulose  and  sheet-iron  with  a  stirrup 


490 


DISEASES  OF  THE  HIP. 


to  which  rubber  bands  are  attached  to  exert  traction.  The  perineal 
pad  is  covered  with  a  rubber  tube  filled  with  fluid,  preferably  glycerin. 
Instead  of  plaster  or  cellulose,  other  materials  may  be  used:  wood,  glue, 
silicate,  felt,  etc.     [Cellulose  is  a  kind  of  wood  fibre.] 

A  well-fitting  plaster  splint  may  be  used  if  portable  apparatus  are  not 
available.  Surgeons  are  indebted  particularly  to  Lorenz  for  the  technie, 
which  is  followed  here:  all  that  is  necessary  are  plaster-of-Paris  roll- 
bandages  and  an  iron  brace,  which  any  mechanic  can  make.  A  plaster 
splint  is  applied  smoothly  from  the  lower  part  of  the  thorax  to  the 
middle  of  the  thigh.  After  it  has  dried  thoroughly  in  one  or  two  days, 
the  iron  brace  (Fig.  310)  is  bound   on  firmly  with  muslin  bandages. 


Fig.  313. 


Fig.  314. 


Billroth'*  plaster-of-Paris  splint. 

Traction  is  by  means  of  an  elastic  band;  the  splint  is  cheap  and  durable 
(Fig.  311),  and  can  be  made  removable  and  readjustable  (Fig.  312). 

The  plaster  splint  without  the  brace  is  also  very  serviceable  if  it 
includes  the  foot  and  extends  to  the  lower  border  of  the  ribs,  fitting 
accurately  about  the  pelvis  to  insure  uniform  pressure.  In  all  severe 
cases  it  is  better  to  include  the  other  thigh  also  and  unite  both  thighs 
by  a  transverse  piece.  This  gives  very  good  fixation  and  allows  the  child 
to  go  about  with  a  walking  chair.  (Figs.  313  and  314.)  In  applying 
such  extensive  plaster  splints  it  is  an  advantage  to  use  special  extension 
and  immobilization   appliances  like  those  suggested   by  Scheinpflug, 


TUBERCULOSIS  OF  T1IE  HIP-JOIST.  491 

v.  Bruris,  and  others.  The  author  uses  Sehede's  tal)le,  with  exeellent 
results.    The  patient  lies  with  his  shoulders  upon  the  table,  the  perineum 

is  supported  against  a  padded  upright,  and  the  limb  is  held  extended 
either  by  means  of  a  screw  appliance  or  by  an  assistant,  and  the  plaster 
bandages  applied.  Wieting  recommends  suspending  the  patient  in 
order  to  apply  the  splint  in  the  position  in  which  it  will  be  used.  He 
employs  a  sort  of  felt  bathing-tights,  in  which  the  patient  is  suspended 
by  a  rope  and  pulley  attached  to  a  Beely-frame  or  a  ring  in  the  door-jam. 
The  head  is  also  slightly  suspended.  The  plaster  splint  is  put  on  over 
the  felt  tights  after  adhesive-plaster  strips  have  been  applied  to  the  limb 
and  weighted.  A  walking  brace  is  incorporated  in  the  splint  up  to  the 
thigh,  extending  about  an  inch  below  the  sole  of  the  foot.  In  about 
two  days  the  sound  foot  is  raised  on  a  thick  sole  and  the  patient  allowed 
to  go  about.  A  removable  splint  may  be  made  of  cellulose  or  celluloid 
instead  of  plaster. 

All  splints  are  worn  until  the  joint  is  not  sensitive  to  the  body-weight 
or  to  a  blow  upon  the  head  of  the  trochanter.  The  splint  is  then  replaced 
by  a  removable  sheath  splint,  leaving  the  knee  free.  Proper  mechanical 
treatment  certainly  has  a  favorable  effect  upon  the  mortality.  Recently 
the  author  has  followed  all  the  cases  treated  for  years  with  sheath  splint 
apparatus,  and  has  found  that  recovery  with  a  movable  joint  is  possible 
if  the  patients  are  taken  in  hand  early.  This  is  usually  not  the  case, 
however,  and  a  certain  amount  of  stiffness  is  generally  the  result.  There 
is  always  shortening  of  from  \  to  \\  inches  if  the  process  is  well  advanced 
at  the  beginning  of  treatment.  If  the  orthopedic  measures  are  consistent 
and  exact,  the  later  position  of  the  limb  is  relatively  good  compared 
with  previous  results.  In  most  of  the  cases  the  author  has  been  able 
to  obtain  the  desired  position,  namely,  slight  flexion  and  abduction. 
One  no  longer  sees  the  severe  flexion  and  adduction  contractures 
formerly  observed. 

Abscesses  are  less  frequent  with  the  above  treatment  than  with  the 
extension  treatment  alone,  and  their  course  is  decidedly  influenced  by 
exact  fixation,  extension,  and  disencumbrance  of  the  joint.  Abscesses 
or  fistulas  are  not  a  counterindication  to  the  ambulant  method,  as  a 
fenestrum  can  be  cut  in  the  splint  and  the  abscess  aspirated  and  iodoform 
glycerin  injected.  The  10  per  cent,  emulsion  in  glycerin  (v.  Brims' 
iodoform  oil)  is  the  best.  As  the  mixture  is  not  easily  absorbed,  its 
local  action  lasts  longer. 

Many  attempts  have  been  made  to  influence  the  process  by  injecting 
iodoform  directly  into  the  joint,  using  from  4  to  30  c.c.  at  intervals 
of  from  eight  to  fourteen  days  according  to  the  age  and  reactivity  of 
the  patient.  Krause  inserts  a  long  needle  above  the  trochanter  perpen- 
dicular to  the  axis  of  the  thigh  and  in  the  frontal  plane,  the  patient  being 
in  the  dorsal  position  with  the  limb  extended,  adducted,  and  rotated 
slightly  inward;  the  needle  slides  over  the  head  into  the  joint  to  the 
floor  of  the  cavity,  v.  Biingner  locates  the  femoral  artery  as  it  crosses  the 
horizontal  ramus  of  the  pubis  and  inserts  the  needle  in  the  sagittal  direc- 
tion at  the  inner  border  of  the  sartorius  in  a  line  drawn  from  the  tip 


492  DISEASES  OF  THE  HIP, 

of  the  great  trochanter  to  the  artery  at  the  point  mentioned.  Rise  of 
temperature,  weakness,  and  pain  may  follow  the  injection,  but  usually 
disappear  on  the  second  day.  Schuller  uses  a  15  per  cent,  emulsion 
of  iodoform  in  glycerin  or  water  with  0.5  to  1  per  cent,  guaiacol,  or 
5  per  cent,  mucilage  of  gum  arabic  and  1  per  cent,  of  carbolic  acid. 
Instead  of  glycerin,  gelatin  or  oil  (v.  Bruns)  may  be  used.  Landerer 
recommends  highly  an  injection  every  other  day  of  a  1  to  5  per  cent, 
aqueous  solution  of  sodium  cinnamate  into  the  diseased  tissue,  and  in 
adults  <rL  to  I  grain  into  the  veins.  He  injects  2  to  3  c.c.  of  a  1  per 
cent,  cinnamic  acid  glycerin  into  abscesses  about  every  ten  days,  appar- 
ently with  good  results.  Menard  obtained  good  results  by  injecting 
camphor  naphtol;  of  108  cases  of  abscess,  04  recovered  after  two  to  ten 
injections,  in  6  a  fistula  persisted.  Lannelongue  injected  chloride  of  zinc 
about  the  focus  to  stimulate  the  production  of  a  fibrous  capsule  (methode 
sclerogene). 

If  unsuccessful  with  these  measures  and  the  suppuration  continues, 
it  is  best  to  open  the  abscess  widely,  scrape  out  all  diseased  tissue  with 
a  sharp  spoon,  and  inject  iodoform-glycerin  and  pack  the  wound. 
Recovery  is  often  more  rapid  thus  than  by  any  other  means. 

Correction  of  any  existing  contracture  position  in  recent  cases  is 
easily  effected  in  a  portable  apparatus  by  means  of  a  special  splint 
and  sector  appliance.  If  a  plaster  splint  is  to  be  used  the  author 
would  recommend  Dollingers  method  in  preference  to  all  others 
to  correct  any  contracture:  two  smooth,  polished,  rounded  or  angular 
iron  rods  about  h  'nc'n  m  diameter  (Dittel  rods)  are  laid  under  the 
patient,  with  a  layer  of  cotton  over  them,  so  that  they  diverge  down- 
ward from  between  the  shoulders  enclosing  an  angle  of  about  30  to 
40  degrees.  (Fig.  315.)  The  patient's  shoulders  rest  upon  the  edge  of  the 
table,  the  rest  of  the  body  and  the  thighs  upon  the  rods,  which  are 
supported  upon  a  horse  of  the  same  level  as  the  table.  The  sound  limb 
is  placed  upon  the  rod  so  that  the  back  of  the  outer  malleolus  rests 
upon  it,  and  the  affected  thigh  is  lifted  so  that  the  pelvis  lies  flat  upon 
the  rods;  the  pelvis  and  sound  limb  are  then  enclosed  with  the  rods 
in  a  plaster  splint  so  that  the  lordosis  is  overcome  fully.  After  the 
splint  has  hardened  sufficiently,  the  affected  limb  is  extended  slowly 
and  carefully  until  the  inner  malleolus  rests  upon  the  second  rod;  the 
thigh  is  then  hyperextended  if  possible.  The  limb  is  then  enclosed  with 
the  rod  in  a  plaster  splint  in  the  same  manner  while  traction  is  made  on 
the  foot.  (Fig.  316.)  After  the  plaster  has  hardened  the  rods  are 
drawn  out  and  the  splint  on  the  sound  limb  removed.  If  the  correction 
is  not  completed  at  the  first  sitting,  the  manipulation  is  repeated  in 
eight  days.  If  the  limb  is  properly  immobilized,  extended,  and  dis- 
encumbered, the  patient  may  go  about  with  crutches  or  a  walking 
chair.  If  the  plaster  splint  is  uncomfortable,  it  may  be  replaced  after 
a  few  weeks  by  one  of  the  various  apparatus. 

The  results  of  conservative  treatment  are  shown  by  the  following 
figures:  The  recent  statistics  of  v.  Bruns  and  Wagner  of  321  cases,  of 
which  133  were  without  suppuration,   188  with,  give   179  recoveries 


TI'UKRCULOSIS  OF  THE  HIP  JOINT. 


I.f, 


(66  percent.).  Of  the  non-suppurative  cases  76  per  cent,  recovered, 
and  of  the  suppurative  12  per  cent,  recovered;  127  died  (40  per  cent.), 
of  which  30  were  uon-suppurative  (23  per  cent.),  and  97  suppurative 
(52  per  cent.).  The  mortality  given  in  other  statistics  is  about  the  same. 
(Billroth,  Rosmanit,  Thausing,  London  Committee  report,  Kdnig.) 

Fig.  315. 


Fig.  316. 


Dollinger's  method. 

The  mobility  in  the  eases  of  v.  Brims  and  Wagner  which  recovered 
was  reduced  in  19  to  half  the  normal,  in  27  much  more,  and  in  82 
there  was  complete  ankylosis,  the  ankylosis  in  the  suppurative  cases 
being  much  more  complete  than  in  the  non-suppurative.  There  were 
contractures  in  82  per  cent,  and  shortening  in  all  but  4  cases. 

Operation. — If  conservative  treatment  is  not  successful,  much  may 
still  be  accomplished  by  operation.  The  indications  and  counter- 
indications  of  operation,  either  arthrectomy  (Schede)  or  the  more 
frequent  resection,  are  as  follows:  Operation  is  counterindicated  by 
general  weakness  either  from  amyloid  degeneration  (hydrops,  albumin- 
uria), general  tuberculosis,  or  advanced  age.     Operation  is  indicated 


494  DISEASES  OF  THE  HIP. 

if  the  coxitis  threatens  life;  by  profuse  severe  suppuration  as  produced, 
for  example,  by  large  sequestra;  by  putrefaction  of  pus  and  high  septic 
fever;  by  pelvic  abscesses;  in  short,  whenever  it  is  necessary  to  secure 
drainage  for  exhausting  suppuration,  v.  Volkmann  has  repeatedly 
noticed  that  coxitis  beginning  like  caries  sicca  may  suddenly  assume  a 
very  serious  character  and  require  operation  if  the  granulations  become 
purulent  and  more  or  less  septic.  If  spontaneous  dislocation  follows 
suppuration  and  perforation,  operation  is  indicated  if  the  pressure  of 
the  head  produced  by  its  false  position  causes  protracted  suppuration 
of  the  necrosed  surface  of  the  ilium. 

Schmidt,  Bardenheuer,  and  Sprengel  have  removed  the  entire  acetabu- 
lum successfully  when  it  was  the  chief  site  of  the  disease.  Such  extreme 
measures  are  rarely  necessary;  in  the  majority  of  cases  it  will  be  sufficient 
to  clean  out  the  cavity.  Arthrectomy  has  seldom  been  performed. 
Schede  has  shown  that  in  many  instances  it  is  possible  to  clean  up  the 
head  and  acetabulum  and  replace  the  head  in  the  cavity.  The  results 
of  resection  obtained  and  studied  in  various  clinics  in  the  last  few  years 
show  clearly  the  advantages  of  the  methods  of  Henle,  Pedolin,  Marsch, 
and  Konig.  At  the  same  time  these  statistics  are  striking  evidence  of 
the  favorable  results  of  conservative  treatment.  The  "bad  results"  and 
the  mortality  of  resection  compared  with  conservative  treatment  are 
partly  due  to  the  fact  that  only  the  most  unfavorable  cases  are  operated 
upon.  The  functional  results  of  conservative  treatment  are  almost 
always  better  than  those  of  operation.  Operation  has  one  unmistakable 
advantage,  it  hastens  recovery;  but  in  contrast  to  this  the  high-grade 
shortening  and  marked  contractures  which  may  develop  later  are  counter- 
indications  except  in  the  very  severe  cases  of  suppuration  in  which  con- 
servative treatment  fails. 


DEFORMING  AFFECTIONS   OF  THE  HIP-JOINT. 

Arthritis  Deformans  of  the  Hip-joint  (Coxitis  Deformans;  Arthritis 
Sicca  Coxes). — By  arthritis  deformans  of  the  hip-joint  is  understood  an 
affection  characterized  by  degenerative  and  hyperplastic  changes.  Two 
forms  are  to  be  sharply  distinguished  from  each  other:  the  juvenile  and 
senile,  differing  in  important  points  but  presenting  the  same  pathological 
picture.  The  juvenile  (traumatic)  form,  seen  at  any  age  and  termed 
juvenile  only  to  contrast  it  with  the  typical  senile  affection,  only  occurs 
after  violence  applied  to  the  hip  in  the  same  way  that  it  happens  after 
trauma  in  the  other  joints.  In  adolescence  it  is  ordinarily  a  very  rare 
occurrence.  The  process  develops  in  a  relatively  short  time  after  the 
injury,  exceptionally  after  one  or  two  years.  Senile  arthritis  deformans 
(malum  coxa?  senile),  on  the  other  hand,  occurs  irrespective  of  any 
attributable  violence,  develops  gradually  and  slowly,  affects  only  one 
hip,  and  is  more  frequent  in  men  than  in  women.  Both  forms  are 
without  fever,  and  in  the  advanced  stage  produce  marked  impairment 
of  motion,  but    never  complete  ankylosis.    There  are  never  any  florid 


DEFORMING  AFFECTIONS  OF  THE  II IP-JOINT. 


495 


symptoms  of  inflammation  or  suppuration.     Life  is  never  threatened; 
no  particular  class  of  people  are  predisposed. 

Pathological  Anatomy. — The  deforming  process  is   ushered   in  by  a 
fraying  out  of  the  cartilage;  later  proliferation  occurs  at  the  margin  of 


Arthritis  deformans  with  marked  villous  formation,      (v.  Bruns.) 

the  joint  and  numerous  villi  form.  (Fig.  317.)  Where  the  cartilages 
rub  together  they  are  gradually  destroyed,  and  on  the  free  portions  new 
bone  is  formed,  so  that  there  is  gradually  complete  destruction  of  the 


Fig.  318. 


Fig.  319. 


Fig.  320. 


Femur  heads  of  arthritis  deformans.     (Wiirzburg  collection., 

joint,  v.  Volkmann's  description  of  the  changes  is  classical.  At  first  the 
margin  of  the  head  becomes  unevenly  puffed  out  toward  the  shaft  and 
covered  with  an  irregular  growth  of  bone,  like  stalactites  or  knobs. 


496 


DISEASES  OF  THE  HIP. 


(Fig.  3 IS.)  The  head  is  often  greatly  thickened  and  broadened  by  these 
growths  along  the  margin;  it  may  be  the  size  of  a  fist  or  even  larger. 
(Fig.  319.)  At  the  same  time  its  relation  to  the  shaft  is  changed;  it  may 
be  flexed  sharply  or  bent  or  face  sideways  upon  the  neck.  (Figs.  320 
and  321.)  Later  the  neck  is  also  partially  or  entirely  destroyed;  then 
the  head,  broad,  mushroom-  or  cake-shaped,  lies  directly  upon  the  great 


Fig.  321. 


Fig.  322. 


Fig.  323. 


Fig   324. 


Femur  heads  of  arthritis  deformans.     (Wiirzburg  collection.) 

trochanter  (Fig.  322)  or  arches  backward  over  it  with  shell-like  exostoses. 
Sometimes  the  head  appears  as  if  displaced  some  little  distance  downward 
on  the  shaft  so  that  the  tip  of  the  trochanter  rises  above  it  (Fig.  321); 
or  it  may  be  elongated  downward  in  the  shape  of  wedge  or  pyramid 
(Figs.  323  and  324)  and  be  attached  immediately  to  the  great  trochanter, 
the  neck  apparently  being  partially  or  completely  absent. 

Fig.  325. 


Acetabulum  of  arthritis  deformans.     (Wiirzburg  collection.) 

The  acetabulum  usually  presents  a  fairly  true  counterpart  of  the 
deformed  head;  it  is  sometimes  widened,  sometimes  deepened,  the 
margin  being  covered  with  irregular  bony  masses.  (Fig.  325.)  In  spite 
of  the  most  marvellous  deformation  of  the  joint-surfaces,  the  latter 
usually  retain  a  certain  parallelism,  so  that  function  is  impaired  but 
never  completely  lost.    Sometimes  the  deepened  cavity  encloses  the  head 


DEFORMING  AFFECTIONS  OF  THE  HIP-JOINT.  497 

like  a  hollow  sphere,  so  that  the  latter,'  in  spite  of  its  mobility,  cannot 
be  removed  until  it  is  macerated;  or  the  cavity  may  be  widened  more 
than  the  head,  spreading  out  more  and  more  upward  and  backward. 
The  head  then  slides  gradually  and  steadily  upward  in  the  same  direction 
on  the  ilium.    This  is  the  so-called  "wandering  cavity."     (Fig.  326.) 

Etiology. — The  senile  form  as  well  as  the  juvenile  may  follow  injury, 
but  usually  there  is  no  history  of  trauma  and  the  surgeon  is  confronted 
with  a  mystery.  Typical  arthritis  deformans  is  generally  met  with  in 
otherwise  well-nourished  patients  showing  no  trace  of  gout.  That  it  is 
a  symptom  of  gout,  as  one  hears  so  frequently,  can  therefore  be  entirely 
refuted.  The  disease  in  the  hip-joint  is  often  coexistent  with  deform- 
ing inflammation  in  other  joints,  but  more  frequently  occurs  alone. 
From  the  author's  experience  the  senile  form  is  to  be  regarded  as  a 
neurotrophic  disturbance,  but  this  does  not  explain  why  only  one 
hip-joint  is  affected.    The  author  has  often  found  that  the  patients  have 

Fig.  326. 


Acetabulum  of  arthritis  deformans.     (Wiirzburg  collection.) 

undergone  some  severe  mental  disturbance  before  the  disease  or  have 
become  more  or  less  nervous  from  work  and  overexertion.  By  many 
typical  arthritis  deformans  is  regarded  as  a  variety  of  chronic  articular 
rheumatism — in  fact,  a  monarticular  chronic  articular  rheumatism 
(Baumler),  possibly  of  infectious  origin. 

Symptoms  and  Diagnosis. — The  recognition  of  the  juvenile  form, 
occurring  in  the  fifteenth  to  the  eighteenth  year,  is  difficult,  because 
little  is  known  of  the  symptoms  on  account  of  the  rarity  of  the  disease. 
Only  isolated  examples  are  known  in  the  literature.  Maydl  reports  2 
cases  from  personal  observation;  Zesas  published  a  case  of  Kiister  and 
another  of  Riedel.  These  exhaust  the  literature  of  the  pure  juvenile 
form.  Two  cases  of  Midler  occurred  in  laborers  thirty-three  and 
thirty-eight  years  old,  and  one  of  Cornils  in  a  laborer  twenty-nine 
years  old.  In  almost  all  the  cases  trauma  was  antecedent  or  at  least 
suspected. 

Vol.  Ill— 32 


498  DISEASES  OF  THE  HIP. 

The  symptoms  are  described  most  accurately  by  Maydl  in  his  com- 
parison of  2  cases  with  2  of  coxa  vara.  He  emphasizes  the  difficulty 
of  differential  diagnosis.  In  adolescents  the  disease  began  with  pain, 
functional  disturbance,  abnormal  flexion,  abduction  or  adduction  and 
constant  pronounced  outward  rotation  of  the  joint,  shortening  of  the 
limb  (even  lh  inches),  upward  displacement  and  angular  prominence 
of  the  trochanter,  and  atrophy  of  the  hip  and  thigh.  These  are  the 
most  important  symptoms  of  the  juvenile  form,  and  are  very  similar  to 
those  of  coxa  vara,  which  will  be  described  later.  In  the  differential 
diagnosis  it  is  significant  that  in  arthritis  deformans  the  function  of  the 
joint  becomes  more  and  more  impaired  with  increasing  pain,  whereas 
in  coxa  vara,  the  painful  stage,  in  which  motion  is  limited,  may  be 
followed  by  one  free  from  pain  with  a  fair  range  of  motion.  Maydl 
states  that  the  size  of  the  hip,  which,  as  mentioned,  is  frequently  very 
much  increased  in  both  affections,  decreases  in  arthritis  deformans 
simultaneously  with  the  increasing  atrophy  of  the  joint,  but  increases  in 
coxa  vara  if  the  angle  between  the  neck  and  the  shaft  becomes  smaller. 
The  palpation  of  exostoses  is  often  difficult,  and  may  lead  to  error,  as 
bony  irregularities  occur  in  coxa  vara.  The  most  accurate  information 
is  given  by  the  x-ray. 

As  to  the  typical  senile  form,  the  surgeon  is  usually  dealing  with 
individuals  past  the  fortieth  year.  The  first  symptoms  recognized  by 
the  patient  are  fatigue  after  walking  and  radiating  pains  in  the  region 
of  the  sciatic  nerve.  The  limp  soon  follows.  Active  and  passive  motion 
are  still  possible  at  the  outset,  but  the  pain  caused  by  more  active 
movements  soon  leads  to  more  and  more  restricted  use  of  the  limb. 
The  entire  process  is  very  insidious  so  that  the  patient  suffers  for  years 
before  palpation  demonstrates  any  bony  prominences.  The  limita- 
tion of  motion  after  resting,  especially  in  the  morning  on  arising,  is 
characteristic;  the  patient  then  complains  of  more  or  less  stiffness  in 
the  joint,  gradually  passing  away  in  the  course  of  the  day  after  walk- 

In  the  advanced  stage  the  picture  is  very  striking;  deformity  is  then 
present,  the  entire  hip  being  more  prominent,  the  pelvis  higher  than  on 
the  other  side,  the  limb  adducted,  rotated  outward,  and  shortened.  The 
trochanter  lies  above  Roser-Nelaton's  line.  On  palpation  the  site  of 
the  trochanter  is  found  to  be  evidently  broadened  and  bony  prominences 
can  be  felt  from  in  front  corresponding  to  the  neck.  Rotation  and 
abduction  especially  are  limited.  Distinct  crepitus  is  felt  in  the  joint 
on  passive  motion.  The  patient  is  frequently  able  to  elicit  crepitus  by 
contracting  the  muscles.  The  symptoms  do  not  need  to  be  so  typical 
or  pronounced  to  permit  of  diagnosis.  It  suffices  to  strip  the  patient 
and  request  that  the  limbs  be  abducted;  the  inability  to  do  this  which 
goes  hand  in  hand  with  the  decreased  angle  between  the  neck  and 
shaft  is  immediately  recognizable.  Even  at  the  beginning  of  the  disease 
the  spreading  of  the  limbs  is  accomplished  chiefly  by  the  sound  one, 
the  affected  limb  remaining  more  or  less  adducted,  the  pelvis  elevated 
on  the  same  side,  and  the  adductors  very  tense. 


DEFORMING  AFFECTIONS  OF  THE  HIP-JOINT.  499 

At  a  later  stage  the  patients  often  complain  of  paresthesias  in  the 
limb  and  darting  pains  in  the  knee  and  calf.  The  discomfort  may 
prevent  sleep.  The  shortening  gradually  increases,  the  trochanter  rising 
higher  above  Roser-Nelaton's  line.    The  mobility  of  the  limb  gradually 

decreases,  hut  actual  ankylosis  is  very  rare.  A  reflex  atrophy  of  the 
hi])  muscles  follows,  later  increased  by  disuse. 

In  the  differential  diagnosis  the  surgeon  must  always  remember  that 
he  is  not  dealing  with  veritable  symptoms  of  inflammation,  as  in  acute 
articular  rheumatism  or  gout,  but  with  a  slowly  increasing  disease. 
The  infections  diseases  and  tuberculosis  are  excluded  by  the  history. 
In  the  author's  experience  the  affection  is  most  frequently  confused  with 
sciatica,  the  incipient  pains  being  regarded  as  sciatic.  At  the  outset 
such  a  mistake  is  easy  as  there  may  be  paresthesias  and  pain  radiating 
into  the  knee  and  calf.  If  one  makes  it  a  rule  with  patients  suffering 
from  such  pain  not  to  simply  assume  a  sciatica,  but  to  have  the  patient 
stripped  and  the  limbs  spread  apart,  the  limited  abduction  will  be  easily 
recognized. 

Course  and  Prognosis. —As  stated,  the  course  of  the  juvenile  form  is 
rather  rapid,  the  deforming  process  developing  in  one  to  two  years 
after  the  injury,  accompanied  by  pain  and  impairment  of  motion,  until 
the  patient  is  unable  to  walk.  Spontaneous  recovery  is  not  known. 
Occasionally  the  affection  comes  to  a  standstill.  The  course  in  the 
senile  form  is  extremely  insidious.  There  are  no  typical  exacerbations, 
although  the  pain  may  increase  at  various  times.  If  the  deformity  and 
the  atrophy  of  the  muscles  proximal  and  distal  to  the  joint  increases, 
the  pain  and  weakness  in  the  limb  may  render  walking  or  even  stand- 
ing impossible,  so  that  the  patient,  even  against  his  will,  then  becomes 
dependent  on  crutches  or  a  rolling  chair.  The  prognosis  is  unfavora- 
ble, although  it  is  possible  to  alleviate  the  pain  and  somewhat  pre- 
serve the  usefulness  of  the  limb. 

Treatment. — Although  incurable,  it  may  be  possible  to  arrest  the 
process.  Salicylic  acid  internally  is  usually  without  effect.  Salophen, 
45  to  60  grains  daily,  may  lessen  the  pain.  Arsenic,  potassium  iodide, 
and  cod-liver  oil  are  recommended,  but  have  only  a  temporary  effect 
upon  recent  cases.  External  applications  of  iodine,  ichthyol,  gray 
ointment,  or  iodovasogen  do  no  apparent  good.  A  course  of  treatment 
at  one  of  the  various  baths,1  either  thermal,  mud,  salt,  or  sulphur,  some- 
times increases  the  mobility.  Even  simple  cold  wet  compresses  may 
have  a  favorable  effect  upon  the  process.  Hot-air  baths  may  quiet  the 
pain. 

All  the  above  measures  are  usually  temporary  in  their  effect.  The 
portable  protective  apparatus,  on  the  other  hand,  has  a  healing  influence 
upon  the  entire  process,  v.  Volkmann  and  Konig  have  reported  its 
beneficial  effects,  and  the  author  has  tried  it  systematically  in  a  sufficient 
number  of  cases  to  testify  to  its  excellent  results  if  properly  applied.    A 

'Thermal  mineral  springs:  Gastein,  Wildbad,  Wiesbaden,  Teplitz,  Warmbrunn,  Baden-Baden; 
mud  and  salt  baths:  Franzensbad,  Pistyan,  Kissingen,  Karlsbad,  Nauheim;  sulphur  baths:  Eilsen, 
Nenndorf,  Weilbach,  Aachen. 


500 


DISEASES  OF  THE  HIP. 


well-fitting  sheath  splint  is  the  best  treatment,  and  should  be  applied 
as  soon  as  possible — not  after  the  patient  has  passed  a  summer  at  a 
bath  and  so  lost  valuable  time.  By  it  the  hip-joint  is  unburdened,  the 
joint-surfaces  are  held  apart,  the  false  position  of  the  limb  corrected, 
the  patient  is  made  extremely  comfortable,  and  the  destructive  rubbing 
of  the  joint-surfaces  upon  each  other  thus  prevented  and  the  process 
checked  or  brought  to  a  standstill.  The  splint  should  fit  accurately,  be 
made  on  a  model  of  the  limb,  and  be  fastened  to  a  pelvic  brace  to 
secure  greater  firmness.    (Fig.  327.)    Patients  who  cannot  walk,  or  who 


Fig.  32- 


Fig.  328. 


Sheath  apparatus  for  arthritis  deformans 
of  the  hip. 


Changes  in  the  upper  end  of  the 
femur  in  tabes. 


go  about  with  difficulty  on  crutches,  learn  to  walk  in  the  apparatus  with 
a  cane  and  finally  without  the  latter. 

It  is  very  important  to  strengthen  the  atrophied  muscles  at  the  same 
time  by  massage,  electricity,  and  gymnastics.  As  soon  as  the  deformity 
is  approximately  corrected  the  apparatus,  previously  worn  night  and 
day,  is  removed  every  morning  and  the  muscles  of  the  entire  limb  mas- 
saged and  faradized;  then  follow  gymnastic  exercises  to  increase  the 


DEFORMING  AFFECTIONS  OF  THE  HIP-JOINT.  501 

mobility  of  the  joint  in  all  directions  and  strengthen  the  muscles,  espe- 
cially the  abductors.  This  treatment  systematically  applied  often 
accomplishes  wonders.  The  author  has  seen  advanced  cases  com- 
pletely checked,  and  could  feel  and  verify  with  the  x-ray  the  diminution 
of  exostoses.  Joints  previously  almost  immovable  can  be  moved  freely 
in  all  directions.  If  for  any  reason  the  treatment  is  not  applicable,  the 
patient  should  be  urged  to  use  the  limb  as  much  as  possible  in  spite 
of  the  pain,  as  rest  is  poison  for  such  a  joint.  Very  severe  cases  have 
been  operated  upon.  W.  Midler  performed  subperiosteal  resection  in 
youthful  patients  with  success.  Riedel,  Kiister,  Maydl,  and  Konig  have 
favorably  influenced  the  pain  and  mobility  by  resection. 

Neuropathic  Affections  of  the  Joint. — The  functional  disturbances, 
the  so-called  joint-neuralgias  and  hysterical  joint,  will  be  described 
under  contractures,  as,  aside  from  the  pain,  the  latter  represent  the 
chief  symptom  of  the  disease.  Tabes  and  syringomyelia,  and  stab- 
wounds  of  the  spinal  cord,  produce  an  arthropathy  of  the  hip-joint,  the 
last-mentioned  the  Brown-Sequard  paralysis,  with  sudden  swelling  of 
the  hip-joint.  (Mitchell.)  The  Charcot  joint  of  tabes  affects  the  hip 
rather  frequently :  among  149  cases  Flatow  found  unilateral  involvement 
of  the  hip  in  38,  bilateral  in  9.  The  onset  was  usually  sudden;  the 
joint  wras  distended  with  serous  or  bloody  fluid  without  redness  of  the 
skin,  pain,  or  fever.  The  joint-surfaces  wrere  destroyed  rapidly  and  sub- 
luxation or  dislocation  followed.  There  was  simultaneous  proliferation 
of  bone  as  in  arthritis  deformans.  Dislocation  took  place  without  any 
special  violence  as  cause,  occasionally  in  bed  without  being  recognized 
by  the  patient.  The  appearance  of  the  joint  is  very  characteristic;  the 
head  may  be  lacking,  the  atrophic  upper  end  of  the  femur  ending  in  a 
point  corresponding  to  the  great  trochanter.  (Fig.  328.)  The  pelvis 
on  the  same  side  is  atrophic,  v.  Hacker  found  the  same  deformity  of 
the  femur  on  opening  a  tabetic  joint;  the  cavity  was  full  of  villous 
growths;  the  capsule,  of  which  no  trace  could  be  found,  was  replaced 
by  similar  tissues.     (Lotheissen.) 

The  disease  may  appear  before  the  ataxia — in  fact,  its  typical  course 
may  lead  to  the  diagnosis  of  tabes.  (Lotheissen.)  If  the  joint  is  much 
destroyed,  its  abnormal  mobility  renders  it  incapable  of  supporting 
the  body.  The  milder  cases  may  be  benefited  by  a  wTell-fitting  sheath 
splint  and  pelvic  brace  (Fig.  327)  and  massage.  The  severer  cases 
have  been  operated  upon  repeatedly;  Schede  performed  arthrotomy 
successfully;  v.  Bergmann,  Rotter  and  v.  Hacker  resected  the  joint. 
After  operation  it  is  best  for  the  patient  to  wear  a  supporting  apparatus 
permanently. 

Syringomyelia  produces  a  neuropathic  joint  less  frequently  than 
tabes  and  more  commonly  affects  the  upper  extremity.  According  to 
Schlesinger's  statistics,  the  hip  was  involved  in  only  4  of  97  cases.  The 
hip  affection  usually  follows  trauma;  the  marked  swelling  in  the  joint 
develops  without  much  pain.  Swelling  about  the  joint  may  also  be 
very  pronounced.  The  articular  surfaces  are  absorbed  and  dislocation 
follows  (atrophic  form),  or  there  is  a  deforming  proliferation  of  bone  in 


502  DISEASES  OF  THE  HIP. 

and  around  the  joint  (hypertrophic  form).  If  a  good  supporting  appa- 
ratus is  worn  from  the  outset  of  the  disease,  the  results  are  good.  Opera- 
tion is  hardly  indicated,  for  as  the  disease  advances  the  old  or  even 
worse  conditions  usually  develop  in  the  operated  joint. 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  HIP-JOINT. 

Contracture  and  ankylosis  result  from  a  great  variety  of  causes. 
The  infrequent  cicatricial  contraction  of  the  skin  on  the  flexor  surface 
due  to  burns,  or  the  rare  gangrene  of  bubo  may  produce  a  flexion  con- 
tracture of  the  joint.  Contraction  of  the  ligaments  usually  flexes  and 
also  adducts  or  abducts  the  thigh  (desmogenic  contracture).  Con- 
traction of  the  periarticular  connective  tissues  may  be  due  to  a  psoas 
abscess,  suppuration  of  the  deep  glands,  or  pure  atrophic  shrinkage  of 
the  connective  tissue,  chiefly  the  fascia  lata,  resulting  from  the  joint 
being  held  in  an  abnormal  position  for  a  long  time,  as,  for  example, 
with  suppuration  of  the  inguinal  glands. 

Pure  myogenic  flexion-contracture  of  the  hip-joint  is  represented  by 
the  contraction  of  the  psoas  resulting  from  spondylitis.  According  to 
Bardeleben,  rheumatism  may  produce  a  muscular  contracture  of  the 
hip — in  fact,  he  regarded  many  of  the  cases  of  so-called  voluntary 
limp  in  children  which  were  reported  later  as  instances  of  healed  coxitis, 
as  of  this  nature.  The  thigh  is  flexed  and  adducted;  every  motion  is 
painful  so  that  the  child  cries  out  before  the  limb  is  touched.  The  con- 
tracture is  overcome  under  anaesthesia  and  yields  rapidly  to  appropriate 
mechanical  treatment,  the  same  as  rheumatic  torticollis  and  other 
rheumatic  contractures. 

The  contractures  of  nervous  origin  will  be  discussed  under  the  effects 
of  paralysis  in  the  following  section.  Hysterical  contracture  and 
Brodie's  joint-neuralgia  are  given  as  forms  of  "neurotic  contrac- 
ture." According  to  Wernher,  the  symptoms  are  quite  characteristic; 
pains  of  a  neuralgic  character  and  radiating  in  the  area  of  the  ob- 
turator and  crural  nerves  are  associated  with  permanent  reflex  con- 
traction of  special  groups  of  muscles,  especially  the  adductors  and 
inward  rotators.  The  contraction  is  entirely  involuntary  and  fixes  the 
joint  as  completely  as  ankylosis.  Other  thigh  muscles,  especially  the 
quadriceps  and  the  glutei,  are  relaxed  and  unable  to  move  the  limb; 
they  do  not  respond  to  the  will-impulses  and  only  weakly  or  not  at  all  to 
electricity.  The  entire  extremity  is  backward  in  development.  Exam- 
ination under  anaesthesia  gives  no  trace  of  joint-inflammation,  so  that 
coxitis  is  easily  excluded.  The  two  diseases  are  sometimes  confused, 
however,  particularly  as  joint-neuralgia  occurs  chiefly  in  young  robust 
children.  The  treatment  of  these  so-called  nervous  contractures  is 
chiefly  mechanical;  massage,  gymnastics,  douches,  sea-baths,  faradiza- 
tion, and  continuous  weight-extension  at  night  usually  lead  to  rapid 
recovery.  By  far  the  largest  majority  of  cases  of  so-called  contracture 
and  ankylosis  of  the  hip  are  due  either  to  arthritis  deformans  or  pre- 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  HIP- JOINT.      503 

vious  inflammation  of  the  joint  (arthrogenic  contracture).  Tuberculosis 
is  more  frequently  the  cause  than  the  infectious  diseases,  such  as  measles, 
scarlet  fever,  typhoid,  smallpox,  pyaemia,  acute  articular  rheumatism,  and 
acute  osteomyelitis.  The  stiffness  of  the  joint  following  rheumatism  and 
the  infectious  inflammations  is  usually,  and  not  rarely,  due  to  complete 
bony  ankylosis.  The  stiffness  following  tuberculous  coxitis  should  be 
regarded  as  a  contracture. 

The  condition  of  an  ankylosed  joint,  according  to  Gurlt,  is  somewhat 
as  follows:  The  muscles  about  the  joint  are  either  merely  more  firm 
and  paler  than  usual  or  transformed  into  thick,  dense  connective 
tissue,  the  ligaments  also  being  greatly  thickened.  The  head,  usually 
diminished  in  size,  is  united  to  the  frequently  enlarged  and  shifted 
cavity  either  by  connective  tissue  or  bone  or  an  outer  layer  of  bone. 
The  part  of  the  upper  end  of  the  femur  brought  into  contact  with  the 
pelvis  by  its  abnormal  position  is  often  united  to  it  by  bone.  This 
occurs  especially  in  dislocation,  in  which  case  the  old  cavity  is  also 
filled  with  bone.  The  neck  is  usually  intact  after  rheumatism  or  osteo- 
myelitis, or  an  inflammation  causing  ankylosis.  The  head  is  occasionally 
eroded  only  at  the  margin,  the  rest  of  the  head  on  section  being  of  nor- 
mal size,  but  fused  indistinguishably  with  the  acetabulum  by  the  new 
growth  of  spongiosa  created  in  response  to  the  static  demands.  In 
tuberculous  ankylosis  only  a  portion  of  the  neck  remains,  the  deformed 
head  lying  like  a  mushroom  immediately  upon  the  intertrochanteric 
line.  Numerous  pointed  and  pronged  exostoses  may  extend  into  the 
surrounding  muscles. 

The  thigh  may  be  ankylosed  in  almost  any  position.  The  affection 
may  be  bilateral,  rheumatism  being  the  chief  cause,  rarely  tuberculosis. 
In  the  bilateral  form  the  thighs  are  more  frequently  abducted  (Jovers, 
Jones,  Bryant,  v.  Brims,  v.  Langenbeck,  Billroth,  v.  Volkmann,  Konig, 
Maas,  Rossander,  Mordhorst,  wStudensky,  Permann,  and  others)  than 
adducted  (Ledderhose,  Helferich).  Equally  rare  are  the  bilateral  anky- 
loses in  extension  (Lund)  or  pure  flexion  (C.  O.  Weber).  With  the 
exception  of  ankylosis  in  extension,  the  bilateral  forms  always  cause 
contractures  at  the  knee-joint. 

Symptoms. — The  symptoms  of  pure  extension  or  flexion  contracture 
or  ankylosis  require  no  explanation.  The  symptoms  of  the  other 
anomalous  positions  depend  more  upon  the  degree  of  deviation  from 
the  normal  position  than  upon  the  nature  of  the  fixation,  whether  con- 
tracture or  ankylosis. 

The  rare  ankylosis  in  extension  compels  the  patient  to  rotate  the 
pelvis  forward  on  the  same  side  in  order  to  advance  the  foot  in  walking. 
The  mobility  of  the  sacro-iliac  synchondrosis  and  of  the  vertebral 
joints  is  usually  directly  proportional  to  the  duration  of  the  affection, 
so  that  locomotion  gradually  improves.  The  mobility  of  the  vertebra? 
is  particularly  essential  for  comfort  in  sitting.  As  the  thigh  cannot  be 
flexed,  the  patient  has  to  sit  on  the  edge  of  the  chair  and  bend  the  lum- 
bar vertebra?  forward.  In  all  the  other  forms  the  parallelism  of  the 
limbs  in  walking  is  effected  partially  by  the  movement  of  the  pelvis, 


504  DISEASES  OF  THE  HIP. 

chiefly  by  the  vertebrae.  Thus  a  flexion  attitude  of  the  hip  is  compen- 
sated in  standing  or  walking  by  pronounced  inclination  of  the  pelvis 
and  lordosis,  recognizable  by  the  prominence  of  the  affected  hip.  In 
the  dorsal  recumbent  position  the  curvature  of  the  spine  forms  an  arch 
under  which  the  hand  can  be  easily  passed. 

If  the  limb  is  fixed  in  abduction,  the  pelvis  rotates  downward  on  the 
affected  side  on  its  sagittal  axis,  upward  on  the  sound  side,  the  spine 
being  scoliotic  toward  the  affected  side.  If  the  limb  is  fixed  in  flexion 
and  abduction,  the  pelvis  and  spine  are  straight  if  the  limb  is  supported; 
but  if  the  latter  hangs  down,  the  pelvis  inclines  forward  and  to  the 
affected  side,  the  buttock  projects  more  prominently,  and  the  spine 
becomes  lordotic  and  scoliotic  toward  the  affected  side.  If  the  limb  is 
fixed  in  adduction,  in  order  to  walk  the  pelvis  must  be  lifted  on  the 
affected  side  and  the  spine  curved  convexlv  toward  the  sound  side. 
Flexed  and  adducted  simultaneously,  the  limb  presents  the  typical 
picture  described  under  tuberculous  coxitis. 

The  shortening  present  in  all  cases  of  contracture  or  ankylosis, 
except  in  extension,  increases  the  functional  impairment,  and  may  be 
either  real  or  apparent.  Real  shortening  depends  upon  arrested  devel- 
opment of  the  thigh  or  deformation  of  the  neck,  head,  or  acetabulum. 
Apparent  shortening  is  due  to  the  elevation  of  the  pelvis,  associated 
with  fixation  in  adduction.  Real  and  apparent  shortening  combine  to 
produce  functional  shortening  which  comes  into  play  in  walking;  in 
mild  cases  the  front  part  of  the  foot  can  be  brought  to  the  ground  and 
the  shortening  compensated  to  a  certain  extent;  in  more  severe  cases 
this  is  still  possible  by  the  further  action  of  the  pelvis  and  spine;  in 
the  worst  cases  appropriate  lengthening  apparatus  is  necessary,  or  the 
patient  may  prefer  to  use  crutches  and  allow  the  limb  to  hang  unused. 

Bilateral  fixation  naturally  increases  the  disability  of  the  patient.  If 
both  limbs  are  fixed  in  extension,  the  patient  can  only  walk  by  rotating 
each  side  of  the  pelvis  forward  alternately;  sitting  is  impossible.  If  the 
fixation  is  chiefly  in  marked  flexion,  the  patient  walks  upon  the  hands, 
swinging  the  thighs  forward  between  the  arms.  If  with  flexion  is 
associated  pronounced  abduction,  locomotion  is  either  by  alternately 
rotating  the  body  about  its  long  axis  like  a  balance  wheel,  or  by  hopping 
upon  all-fours  alternately  to  the  right  and  left.  Locomotion  is  most 
difficult  with  bilateral  adduction.  Naturally  the  function  of  the  geni- 
tals is  considerably  impaired  in  females. 

Diagnosis. — A  patient  with  a  stiff  hip-joint  should  be  examined  care- 
fully and  systematically.  With  the  patient  lying  upon  a  flat,  firm 
surface  the  pelvis  is  first  straightened.  Both  thighs  are  flexed  until 
all  curvatures  of  the  spine  are  overcome  and  the  back  is  flat,  the 
affected  limb  being  abducted  or  adducted  until  the  anterior-superior 
spines  are  horizontal  and  at  right  angles  to  the  body  axis.  The  sound 
thigh  is  then  fully  extended  to  give  the  pelvis  the  proper  inclination  by 
the  tension  of  the  iliofemoral  ligament.  On  extending  the  affected 
limb  slowly  the  spine  is  lifted  as  soon  as  the  angle  of  fixation  is  reached. 
The  angle  of  abduction  or  adduction  is  determined  similarly  by  watching 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  HIP-JOINT.       505 

the  anterior-superior  spines.  The  instruments  devised  by  Gutseh, 
Lorenz,  and  Hiibscher  obtain  these  measurements  more  accurately,  and 
therefore  deserve  more  general  use.  It  remains  to  determine  whether 
the  stiffness  is  due  to  contracture  or  ankylosis.  If  in  the  dorsal  position 
the  patient  can  move  the  limb  without  shifting  the  pelvis,  ankylosis  is 
excluded.  If  movement  is  limited,  it  is  very  difficult  to  exclude  simul- 
taneous movement  of  the  pelvis,  a  determination  being  arrived  at  by 
fixing  the  pelvis  very  carefully  and  observing  whether  the  spine  moves 
in  executing  short  passive  movements.  The  stiffness  following  rheuma- 
tism or  infection  is  usually  an  actual  ankylosis.  In  the  deformity  of 
tuberculous  coxitis  slight  passive  motion  is  frequently  possible,  even 
in  the  cases  of  extensive  suppuration  with  numerous  fistulas,  com- 
plete destruction  of  the  joint,  and  spontaneous  dislocation.  Complete 
absence  of  active  muscular  contraction  during  such  movements  indi- 
cates ankylosis.  Springy  motion,  due  to  the  elasticity  of  the  femur, 
may  simulate  motion  in  the  joint.  It  is  impossible  to  determine 
whether  ankylosis  is  fibrous  or  bony,  as  the  movement  of  the  pelvis  is 
the  same  with  both. 

Treatment. — Prophylaxis  is  the  most  important  part  of  the  treatment 
of  so-called  contractures.  In  every  case  of  inflammation  of  the  joint 
the  limb  should  be  placed  in  the  position  of  least  functional  impairment 
in  case  contraction  occurs,  namely,  slight  flexion  and  abduction.  Slight 
flexion  enables  the  patient  to  sit;  abduction  is  most  easily  compensated 
by  the  pelvis.  Contractures  can  be  overcome  by  continuous  weight- 
extension  if  the  joint  is  still  movable.  The  Phelps  frame,  which  I  first 
saw  employed  by  Schede  and  Ktimmell  in  Hamburg,  is  extremely  useful 
for  this  purpose.  Presupposing  a  typical  contracture,  traction  is  first 
made  in  the  axis  of  the  thigh  and  then  gradually  changed  by  shifting 
the  cross-piece  and  pulley  outward  and  downward  to  extend  and  abduct 
the  flexed  and  adducted  limb.  Countertraction  and  fixation  of  the 
pelvis  are  self-understood. 

In  ambulant  treatment  the  flexion  may  be  overcome  by  Stillmann's 
adjustable  "sector"  splint,  incorporated  in  a  plaster  splint  enclosing 
the  pelvis  and  thigh.  Various  apparatus  are  used  by  Ullrich  and  Miiller, 
Bigg,  Bertsch,  Hessing,  and  Busch.  All  these  apparatus  act  slowly. 
It  is  more  rational  to  overcome  the  contracture  before  applying  the 
apparatus.  The  author  advises  preliminary  correction  of  tuberculous 
contractures  unconditionally.  The  adhesive-plaster  weight-extension 
splint  gives  good  results,  but  is  slower  and  keeps  the  patient  in  bed. 
The  plaster  splint  works  quicker  and  is  more  comfortable.  Forcible 
correction  (Redressement-force),  formerly  employed  by  Berend,  Dieffen- 
bach,  and  Langenbeck,  and  recently  recommended  by  Kirmisson  and 
Calot,  stands  in  direct  contrast  to  the  gentler  method  of  Dollinger, 
the  author,  and  Lorenz. 

For  forcible  reduction  the  patient  is  deeply  anaesthetized  and  the 
pelvis  fixed  either  by  apparatus  (Bauer,  Terillon)  or  better  by  Gersuny's 
method,  in  which  the  sound  thigh  is  flexed  firmly  upon  the  abdomen  by 
an  assistant  and  pressure  exerted  by  another  upon  the  anterior-superior 


506 


DISEASES  OF  THE  HIP. 


spine  on  the  affected  side.  The  amount  of  force  exerted  in  carrying 
out  the  movements  upon  the  affected  limb  must  be  gauged  according  to 
the  solidity  of  the  bone,  as  fracture  is  possible.  If  the  neck  should  be 
fractured,  as  observed  by  Rossander,  Tillaux,  Volkmann,  and  others, 
it  would  be  an  advantage,  as  the  limb  could  then  easily  be  placed  in  the 


Fig.  329. 


Lorenz'  correction  apparatus. 


desired  position.  The  extension  obtained  is  then  maintained  by  a 
plaster  splint.  The  method  is  by  no  means  harmless,  as  it  has  been 
followed  by  acute  miliary  tuberculosis  or  acute  suppuration  of  the  joint. 
It  should  not  be  employed  therefore  as  long  as  fistulas  indicate  that  the 
recovery  of  the  primary  disease  is  incomplete. 


Fig.  330. 


Lorenz'  correction  apparatus. 


The  author  is  opposed  to  forcible  correction  of  tuberculous  contractures 
in  general  on  account  of  the  bad  effect  of  active  motion  on  the  process. 
It  is  only  permissible  for  completely  healed  non-purulent  coxitis  in 


rnSTRACTURE  AND  ANKYLOSIS  OF  THE  HIP  JOINT.       507 

young  children  followed  by  pathological  dislocation  of  the  femur;  in 
this  case  the  limb  is  drawn  down  as  far  as  possible  to  its  original  level 
by  forcible  extension.  The  author  makes  the  correction  gradually  with- 
out violence  and  without  anaesthesia.  Recently  Lorenz  has  improved 
this  method  under  the  name  of  "instrumental,  combined  correction  of 
the  hip,"  and  made  it  applicable  to  contractures  of  the  hi])  in  general: 
Upon  an  ingeniously  contrived  "hip-corrector"  the  shortened  limb  is 
drawn  down  while  the  sound  limb  is  pushed  tip.    (Fig.  320.)    If  the  soft 


Fig.  331. 


Fig.  :;:;2. 


Hoffa'.-  abduction  and  adduction  apparatus 


parts  are  too  tense,  especially  the  adductors,  they  are  divided  subcu- 
taneously.  If  a  marked  flexion  contracture  presents  any  difficulty,  it 
may  be  overcome  as  explained  by  Fig.  330.  Immobilization  is  best 
secured  by  applying  a  plaster  splint  while  the  patient  is  still  in  the  appa- 
ratus. 

Dollinger's  method,  previously  described,  is  very  practical.  The 
above  are  the  most  simple  and  effectual  methods.  The  plaster  splint 
has  the  disadvantage  of  being  uncomfortable,  so  that  where  possible  it 


508  DISEASES  OF  THE  HIP. 

is  advisable  to  use  a  sheath  splint.  The  latter  has  the  advantage  of  not 
constricting  the  chest  and  leaving  the  knee-joint  and  ankle-joint  free. 
The  author  employs  the  sheath  splint  as  follows:  Flexion  is  overcome 
by  the  use  of  a  sector,  abduction  by  means  of  a  stiff  iron  strip  fastened 
to  the  outer  side  of  the  apparatus,  with  a  screw  arrangement  at  the  end 
to  push  the  limb  inward.  (Figs.  331  and  332.)  Adduction  is  overcome 
by  screwing  in  the  opposite  direction.  Naturally  all  the  above  methods 
are  applicable  only  to  contractures,  not  to  ankylosis. 

Ankylosis  can  be  overcome  only  by  operation.  Osteoclasis  may  be 
performed  at  any  desired  point  with  Robin's  instrument,  although  this 
method  so  far  has  been  little  used.  According  to  Agut,  osteoclasis  has 
been  done  only  18  times  for  hip  deformities,  twice  unsuccessfully,  twice 
with  fairly  satisfactory  and  14  times  with  good  results.  Osteotomy 
has  been  employed  much  more  frequently. 

In  1826  Rhea  Barton  was  the  first  to  saw  through  the  femur  in  a  line 
running  from  the  middle  of  the  great  trochanter  to  the  base  of  the  neck. 
Kearny  Rodgers  followed  in  1830,  Maisonneuve  in  1847,  and  A.  Mayer 
in  1852,  with  similar  operations,  and  in  1854  v.  Langenbeck  proposed 
the  subcutaneous  operation.  In  1862  Say  re  made  a  curved  resection  of 
the  intertrochanteric  part  of  the  femur,  but  gained  few  followers.  In 
1871  Adams  was  more  successful  with  his  operation  of  sawing  through 
the  neck  subcutaneously.  This  operation  is  certainly  correct  anatomically, 
as  it  attacks  the  bone  very  close  to  the  hindrance  without  shortening  the 
extremitv.  Its  disadvantage  is  the  difficulty  of  subsequent  correction; 
moreover,  it  is  inapplicable  to  the  contracture  of  coxitis  in  which  the 
neck  is  generally  lacking.  Adams  subsequently  abandoned  the  opera- 
tion and  recommended  the  method  of  Gant,  published  in  1872,  of  saw- 
ing through  the  femur  subcutaneously  below  the  trochanter.  This 
operation,  subtrochanteric  osteotomy,  has  been  almost  without  a  com- 
petitor since  its  technic  was  improved  by  v.  Yolkmann  in  1873, 1880,  and 
1885.  v.  Yolkmann  gave  up  the  subcutaneous  method,  and  instead  made 
an  extensive  longitudinal  incision  at  the  posterior  border  of  the  tro- 
chanter, as  it  was  almost  always  necessary  to  remove  part  of  the  femur 
(cuneiform  subtrochanteric  osteotomy).  The  harsh  saw  was  replaced 
at  the  same  time  chiefly  by  the  sharp  chisel. 

Wedge-shaped  subtrochanteric  osteotomy,  according  to  v.  Yolkmann, 
makes  it  possible  to  correct  the  position  fully,  and  thereby  the  shorten- 
ing due  to  the  elevation  of  the  pelvis.  Union  in  abduction  compensates 
the  shortening  due  to  arrested  growth  as  well  as  that  due  to  dislocation. 
The  severe  abduction  contracture  with  pronounced  shortening  is  there- 
fore the  principal  indication  for  the  operation.  As  it  is  often  necessary 
to  remove  a  wedge  1  inch  thick,  the  operation  produces  some  shortening. 
Another  disadvantage  is  that  it  fixes  the  hip  in  extension  and  so  pre- 
vents the  patient  from  sitting. 

Accordingly,  for  complete  ankylosis  v.  Yolkmann  later  recommended 
the  so-called  "  chisel  resection  "  to  obtain  a  movable  joint:  A  longitudinal 
incision  is  made  behind  the  trochanter,  the  same  as  v.  Langenbeck's 
incision  for  resection;  the  shaft  is  divided  about  1  inch  below  the  tip 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  HIP-JOINT.       509 

of  the  great  trochanter;  the  upper  end  of  the  femur  is  rounded  off  to  the 
size  of  the  femur  at  about  its  middle.  The  head  is  chiselled  out  to 
form  a  new  wide  and  deep  cavity.  Sufficient  bone  must  be  removed 
to  give  free  play  between  the  rounded  end  of  the  femur  and  the  cavity. 
During  the  after-treatment  forcible  weight  extension  is  applied,  partly 
to  overcome  the  deformity  and  partly  to  prevent  ankylosis.  For  the 
same  reason  passive  motion  should  be  begun  early  and  the  extension 
treatment  continued  under  careful  inspection  for  over  a  year. 

The  indication  for  the  operation  was  later  modified  by  v.  Volkmann; 
it  is  indispensable  for  the  operation  that  the  extremity  should  be  in  fair 
condition,  not  too  much  shortened,  that  there  should  be  no  cicatrix  at 
the  point  of  operation,  and  that  the  muscles  are  still  strong.  "Chisel 
resection"  is  performed  therefore  chiefly  for  bony  ankylosis  of  rheu- 
matic or  infectious  origin.  Recently  Lorenz  advised  preliminary  open 
division  of  all  shortened  soft  parts,  and  showed  that  after  overcoming 
this  resistance  correction  was  possible  by  linear  osteotomy  close  to  the 
angularly  ankylosed  joint.  To  lengthen  the  limb  as  well  as  to  correct 
the  deformity,  the  author  has  recommended  oblique  subtrochanteric 
osteotomy  simultaneously  with  Terrier,  Hennequin,  Landerer,  and 
Lauenstein;  the  contracted  soft  parts  are  first  divided  subcutaneously, 
the  femur  is  then  chiselled  through  from  below  and  without  obliquely 
upward  and  inward.  The  limb  is  then  forcibly  extended  by  the  screw 
so  that  the  fragments  are  shifted  longitudinally  upon  each  other  until 
the  desired  lengthening  has  been  obtained.  The  wound  is  closed, 
covered  with  aseptic  gauze,  and  a  portable  plaster  splint  applied  and 
worn  for  five  weeks.  Energetic  massage  and  gymnastics  follow.  In 
this  manner  the  author  has  repeatedly  lengthened  the  limb  h  to  2  inches, 
besides  correcting  the  deformity. 

Where  fistulas  exist  in  addition  to  the  stiffness,  and  the  head  becomes 
finally  displaced  upon  the  ilium,  resection  of  the  head  is  indicated.  In 
several  such  cases  the  author  has  sawed  obliquely  through  the  head, 
left  the  upper  part  still  attached  to  the  ilium,  and  removed  the  diseased 
upper  part  of  the  femur  to  below  the  trochanter.  By  applying  an 
extension  splint  a  pseudarthrosis  is  formed  between  the  upper  end  of 
the  femur  and  the  remaining  part  of  the  head,  a  movable  joint  is  obtained, 
the  deformity  overcome,  and  the  marked  shortening  reduced  to  about 
1  inch.  This  procedure  is  naturally  only  possible  if  the  head  is  still 
present.  Often  on  opening  the  capsule  only  a  portion  of  the  neck  and 
head  are  found.  The  femur  is  then  chiselled  through  below  the  tro- 
chanter, the  remnant  of  the  neck  and  head  removed,  all  diseased  portions 
of  the  capsule  excised,  the  cavity  cleaned  out,  and  the  after-treatment 
conducted  as  in  v.  Volkmann 's  chisel-resection. 

Bilateral  ankylosis  presents  four  operative  possibilities.  Studensky 
and  Maas  performed  a  chisel  resection  on  both  sides  to  obtain  movable 
joints.  Maas'  2  patients  the  author  examined  five  years  after  operation. 
One,  who  previous  to  the  operation  presented  a  typical  picture  of  bilat- 
eral abduction  ankylosis,  now  gives  all  the  appearances,  even  the  gait, 
of  a  bilateral  dislocation  of  the  hip.     Both  joints  are  freely  movable, 


510  DISEASES  OF  THE  HIP. 

the  patient  can  sit  comfortably,  and  is  greatly  pleased  with  the  result  of 
the  operation.  The  other  patient,  in  whom  the  heads  of  the  femurs 
were  resected,  showed  an  equally  good  result,  v.  Yolkmann,  Liicke, 
v.  Bruns,  Billroth,  Mordhorst  and  others,  performed  a  bilateral  subtro- 
chanteric osteotomy.  This,  however,  makes  it  difficult  for  the  patient  to 
sit.  v.  Volkmann  and  Konig  have  therefore  advised  chisel  resection  on 
one  side  and  subtrochanteric  osteotomy  on  the  other.  The  patient 
thus  has  a  movable  joint  on  one  side  and  is  much  better  off  than  with 
two  stiff  limbs.  From  the  above  the  author  is  obliged  to  regard  v.  Volk- 
mann's  and  Konig's  proposed  operation  as  much  less  practical  than 
that  of  Studensky  and  Maas,  the  more  so  as  the  former  operation  requires 
continuation  of  the  after-treatment  for  years  to  obtain  a  good  functional 
result.  On  the  side  on  which  the  movable  joint  is  desired  bony  union 
has  to  be  combated  by  combining  continuous  weight-extension  with 
portable  apparatus,  systematic  gymnastics,  and  massage. 

Sarrazin  came  to  the  same  conclusions;  among  16  cases  of  bilateral 
resection,  secondary  operation  was  necessary  in  1  instance  for  recur- 
rence; in  4  instances  there  was  ankylosis  on  one  side,  in  11  both  joints 
were  freely  movable  and  stable.  Lorenz  recently  proposed  bilateral 
pelvitrochanteric  osteotomy  to  obtain  a  useful  pseudarthrosis.  Whether 
this  result  is  possible  remains  to  be  seen. 


PARALYTIC  DEFORMITIES  OF  THE  HIP-JOINT. 

Paralytic  loose  joint  is  occasionally  found  after  infantile  spinal  paralysis 
affecting  the  muscles  about  the  hip-joint.  The  looseness  of  the  joint  is 
well  described  by  v.  Volkmann:  "It  not  infrequently  leads  to  hyperexten- 
sion  by  the  gradual  stretching  of  the  front  part  of  the  capsule.  Although 
the  capsule  contains  the  strongest  ligament  in  the  human  body,  the  liga- 
ment of  Bertini,  it  gradually  yields  if  the  patient  allows  the  full  weight 
of  the  body  to  act  constantly  upon  it.  This  in  fact  happens.  The 
pelvis,  instead  of  being  supported,  is  allowed  to  fall  backward  as  far  as 
the  ligament  permits.  The  symphysis  then  appears  to  project  sharply 
forward  and  the  forward  curvature  of  the  lumbar  vertebra?  to  be  increased. 
Younger  children  especially  thus  assume  a  carriage  similar  to  that  in 
congenital  dislocation  of  the  hip."  The  differential  diagnosis  for  the 
two  conditions  has  already  been  given. 

Contracture  of  paralytic  origin,  although  rare,  occurs  at  the  hip,  espe- 
cially in  neglected  children  who  have  lain  for  months  drawn  up  in  bed 
or  who  have  dragged  themselves  about  on  the  floor.  It  is  usually  a 
flexion  contracture,  and  is  described  here  and  not  under  contractures 
of  the  hip,  because  later  it  generally  produces  a  paralytic  dislocation  of 
the  hip-joint. 

Paralytic  dislocation  is  rare;  it  is  known  chiefly  through  the  works  of 
Verneuil,  Reclus,  and  Karewski.  It  only  occurs  when  a  certain  group 
of  muscles  are  paralyzed  and  their  antagonists  are  still  active — evidence 
of  the  correctness  of  Seeligmuller's  "antagonistic-mechanical"  theory  of 


PLATE   XIV 


Coxa  Vera.     iHaedke.) 


COXA   VARA.  511 

the  origin  of  paralytic  deformities.  If  the  abductors  and  the  rotators 
are  inactive  and  the  adductors  active,  the  hip  is  dislocated  upon  the 
ilium  (luxatio  iliaca  femoris  paralytica).  First  an  adduction  con- 
tracture develops;  later  the  posterior  part  of  the  capsule  is  stretched,  and 
if  weighting  of  the  pelvis  is  added  the  head  is  forced  upward  and  back- 
ward against  the  ilium.  Dislocation  in  the  reverse  direction,  forward 
beneath  the  pubis,  results  if  the  rotators  and  abductors  are  more  active 
than  the  adductors.  Reclus  and  Karewski  saw  cases  of  paralytic  dislo- 
cation which  developed  from  the  preceding  contracture  position  while 
the  patients  were  in  bed. 

Symptoms. — The  symptoms  of  paralytic  dislocation  are  very  pro- 
nounced, and  are  usually  associated  with  paralytic  deformities  elsewhere. 
The  limb  is  shortened,  the  trochanter  lies  1  to  3^  inches  above  Roser- 
Nelaton's  line.  The  acetabulum  is  empty;  the  head  of  the  femur  is  felt 
deep  among  the  atrophic  glutei  on  rotating  the  limb;  the  pelvis  is 
atrophic  on  the  same  side ;  the  adductors  react  to  electricity  better  than 
the  other  muscles  of  the  thigh;  the  limb  may  be  fixed  in  adduction  so 
that  spontaneous  abduction  and  outward  rotation  are  impossible. 
(Reclus.)  If  dislocated  forward,  the  limb  is  flexed,  abducted,  and 
rotated  outward.  Extension  and  adduction  are  limited.  The  head 
can  be  felt  close  to  the  ascending  ramus  of  the  pubis;  the  trochanter 
is  covered  by  the  glutei.  Reduction  is  impossible  even  under  anaesthesia 
if  the  dislocation  is  old. 

Treatment. — For  paralytic  loose  joint,  and  to  prevent  or  compensate 
contracture,  the  author  uses  supporting  apparatus  for  the  extremity 
and  the  body.  For  dislocation  one  can  only  recommend  Karewski's 
operation  as  performed  successfully  by  the  author  in  4  cases  of  infra- 
pubic  paralytic  dislocation.  Karewski  exposes  the  joint  by  an  anterior 
longitudinal  incision.  The  contracted  muscles  are  divided,  the  joint 
opened,  the  iliofemoral  ligament  divided,  and  the  glutei,  obturator 
externus  and  interims,  and  pyriformis  separated  from  the  trochanter.  If 
the  dislocation  is  forward,  the  head  can  be  reduced  by  forcible  adduction. 
In  old  dislocations  the  cavity  may  be  too  small  for  the  head  and  need 
chiselling  out.  While  the  limb  is  held  strongly  adducted  the  divided 
muscles  are  sutured  and  the  dressing  and  plaster  splint  applied.  In 
Karewski's  cases  recovery  was  uninterrupted;  passive  motion  was 
begun  in  thnee  weeks;  at  the  end  of  six  weeks  the  patient  went  about 
in  a  supporting  apparatus,  preferably  without  other  aid.  In  3  cases 
apparatus  was  unnecessary.     The  operation  is  worthy  of  trial. 


COXA  VARA. 

Although  the  varus  and  valgus  deformities  of  the  other  large  joints 
have  claimed  the  attention  of  surgeons  for  some  time  and  been  the 
subject  of  numerous  special  and  general  articles,  those  of  the  hip- joint 
were  almost  unstudied  until  the  works  of  E.  Miiller  in  1888,  and  later 
of  Hofmeister  and  Kocher.    The  deformity  was  known  before  Midler's 


512 


DISEASES  OF  THE  HIP. 


studies  (Wernher,  Roser,  Zeiss,  Richardson,  Fiorani,  Monks,  Keetly), 
but  in  the  older  publications  was  not  distinguished  from  other  affections. 
It  was  usually  described  as  a  pathological  rarity.  Hofmeister  noted  that 
the  deformity  was  not  infrequent,  and  was  important  differentially  and 
practically.  Kocher  at  the  same  time  reported  a  particular  variety  which 
he  considered  should  be  called  coxa  vara,  and  demonstrated  convincingly 
its  connection  with  certain  agricultural  occupations.  Manz  also  cited 
its  frequency  among  farm-hands.  Kocher  regarded  it  as  analogous  to 
pes  varus,  the  varus  position  of  the  hip  being  a  combination  of  adduction, 
outward  rotation,  and  hyperextension ;  Miiller,  Hofmeister,  and  others 
considered  the  adduction  alone  as  characteristic,  analogous  to  the 
conditions  in  other  large  and  small  joints  of  the  extremities  (genu 
valgum  and  varum,  cubitus  valgus,  etc.). 


Fig.  333. 


Fig.  334. 


Method  of  determining  the  inclination-angle,     '.\l--berg.) 

Recently  the  author'-  assistant,  Alsberg,  sought  to  define  the  varus 
position  of.  the  hip  more  sharply  in  the  same  way  that  types  have 
been  established  for  the  knee  and  elbow.  Starting  from  the  mid- 
position  of  the  hip-joint,  a  line  through  the  base  of  the  cartil- 
aginous surface  of  the  head  is  about  parallel  to  the  aperture  of 
the  acetabulum.  A  line  in  this  plane  intersecting  the  long  axis  of 
the  femur  forms  an  angle  normally  of  about  41  degrees,  and  is 
termed  the  "inclination-angle."  It  varies  in  individuals  between 
25  and  54  degrees.  If  increased,  it  signifies  an  abduction  posi- 
tion of  the  femur  if  the  joint-surfaces  are  in  the  mid-position — 
namely,  coxa  valga;  if  decreased  or  negative,  it  signifies  an  adduction 
position,  coxa  vara.  (Figs.  333  and  334.  |  The  construction  of  this 
angle  is  important  because  it  is  immaterial  whether  the  coxa  vara  is 
due  to  a  deformity  of  the  head  or  the  neck,  and  equally  immaterial  in 


COXA    VARA. 


513 


Fig.  335. 


which  part  of  the  neck  the  deviation  occurs.  In  this  anatomical  sense 
coxa  vara  is  the  result  of  various  processes,  the  most  important  form, 
as  well  as  the  most  typical,  being  the  coxa  vara  in  adolescence;  the 
description  will  lie  based  upon  the  latter. 

Coxa  Vara  Adolescentium. — Coxa  vara  adolescentium,  although 
occurring  chiefly  at  puberty,  may  begin  in  early  childhood.  It  usually 
develops  quite  gradually  without  much 
subjective  discomfort,  so  that  the  pa- 
tient's attention  is  first  aroused  by  the 
deformity  and  the  functional  impair- 
ment of  the  joint.  Exceptionally  pain 
in  the  joint  occurs  at  an  early  period, 
arousing  suspicion  of  inflammation  un- 
til the  proper  diagnosis  is  made  later  in 
the  disease  or  with  the  .r-ray.  If  the 
onset  is  insidious,  an  accidental  injury 
in  the  painful  stage  of  the  disease  may 
be  regarded  as  the  cause  by  the  pa- 
tient and  lead  to  the  diagnosis  of  dis- 
location of  the  hip;  this  is  important 
with  respect  to  the  legal  judgment  of 
accident  injuries.  (Borchard.)  Fre- 
quently there  is  an  acute  stage  of  spon- 
taneous severe  pain  which  is  apt  to  dis- 
appear under  appropriate  treatment  or 
spontaneously.  This  painful  stage  is 
analogous  to  the  symptoms  of  so-called 
inflammatory  flat-foot.  (Kocher,  Bor- 
chard, Bayer.)  Walking  is  usually 
fatiguing,  and  the  limp  becomes  more 
marked  as  the  deformity  increases. 

Objectively  one  finds  the  tip  of  the 
trochanter!  to  \\  inches  above  Roser- 
Nelation's  line  and  usually  displaced 
slightly  backward.  The  trochanter  also 
lies  farther  from  the  middle  line  of  the 
body.  (Maydl.)  The  muscles  of  the 
hip  and  thigh  are  weaker  than  those 
of    the    sound    side.     A    deep    groove 

between  the  trochanter  and  buttock  muscles  is  characteristic.  In 
pronounced  cases  a  bony  prominence  is  felt  at  the  joint,  like  the  head 
in  forward  dislocation,  which  is  really  the  deformed  neck  ;  otherwise 
there  is  no  swelling  about  the  joint.  Motion  is  free  and  painless 
within  the  limits  defined  by  the  deformity.  The  thigh  is  held  addueted 
or  parallel  to  the  long  axis  of  the  body.  Abduction  is  always  impaired; 
adduction  may  be  normal. 

In  Kocher's  typical  form  the  limb  is  rotated  outward  and  extended, 
inward  rotation  and  flexion  being  limited.    (Fig.  335.)    The  varus  posi- 
Vol.  III.— 33 


Coxa  vara.     (Kocher.) 


514  DISEASES  OF  THE  HIP. 

tion  may  be  combined  with  flexion  and  also  inward  rotation,  however. 
(Hofmeister,  Nasse.)  If  the  affection  is  bilateral,  as  occurs  not  infre- 
quently, there  is  a  pronounced  lordosis  and  a  characteristic  gait  sugges- 
tive of  spastic  spinal  paralysis  or  congenital  dislocation  of  the  hip.  In  coxa 
vara  the  adduction  and  outward  rotation  compel  the  patient  in  walking 
to  lift  the  pelvis  and  swing  the  limb  around  the  other  (Kocher,  Hof- 
meister) ;  in  congenital  dislocation  of  the  hip  the  gait  is  due  to  a  similar 
relation  of  the  muscles  caused  by  the  upward  displacement  of  the 
trochanter.  The  abductors  inserted  on  the  great  trochanter  are  con- 
siderably weakened.  These  abnormal  conditions  produce  the  symptom 
described  by  Trendelenburg  in  congenital  dislocation  of  the  hip,  namely, 
that  in  standing  upon  the  affected  limb  the  pelvis  sinks  toward  the  other 
side  from  the  inability  of  the  abductors  to  hold  the  pelvis  horizontal. 
The  limb  is  shortened,  measured  from  the  external  malleolus  to  the 
anterior-superior  spine,  but  not  to  the  tip  of  the  trochanter.  The  short- 
ening and  the  dipping  of  the  pelvis  produce  a  static  scoliosis.  In  the 
dorsal  position,  if  the  limb  is  flexed  at  the  hip  and  knee,  the  leg  crosses 
the  sound  thigh.  Hofmeister  and  Kocher  call  attention  to  the  fact  that 
patients  with  coxa  vara  often  have  large  bones  and  a  livid  coloring  of 
the  hands  and  feet,  as  first  described  by  Mikulicz  in  genu  valgum,  very 
often  also  flat  feet  and  genu  valgum. 

Pathological  Anatomy. — The  gross  anatomical  relations  have  been 
studied  with  the  x-ray  (Hofmeister)  and  from  a  series  of  excellent 
resection  specimens  (Muller,  Hoffa,  Kocher,  Nasse,  Maydl).  Thus 
far  the  various  authors  are  not  agreed  as  to  a  uniformity  in  the  etiology 
or  the  anatomical  conditions.  The  nature  and  site  of  the  changes  vary 
greatly.  In  some  instances  the  neck  is  simply  bent  and  the  angle  of 
inclination  diminished  (Muller,  Hofmeister,  Hoffa),  in  others  the  de- 
formity is  in  the  epiphyseal  line  of  the  head  (Kocher,  Hofmeister, 
Nasse).  The  neck  may  be  merely  bent  downward  (adduction  curva- 
ture— Muller)  or  in  addition  may  be  curved  backward  (Hoffa),  for- 
ward (Hofmeister,  Nasse),  or  also  rotated  about  its  long  axis  (Kocher). 
The  bend  is  most  frequently  downward  and  backward.  (Hofmeister, 
Manz.) 

The  accompanying  illustrations  are  from  a  subtrochanteric  resection. 
The  backward  and  downward  deflexion  of  the  neck  is  seen  from  in 
front  in  Fig.  341,  and  from  above  in  Fig.  342.  The  angle  between  the 
head  and  neck  was  60  degrees  compared  to  the  normal,  126  degrees. 
(Mikulicz,  125-126;  Lauenstein,  126-129.)  The  inclination  angle 
is  estimated  at  — 7  degrees  in  contrast  to  the  normal  +41  degrees. 
The  head,  representing  normally  about  two-thirds  of  a  sphere, 
in  this  specimen  is  hardly  a  hemisphere  and  lies  directly  upon  the 
lesser  trochanter.  The  head  may  be  rotated  so  that  part  of  the 
cartilaginous  surface  is  outside  of  the  cavity;  thus  a  "compensating" 
subluxation  occurs.  (Alsberg.)  Or  there  may  be  a  compensatory 
growth  of  cartilage  upon  the  proximal  surface  of  the  neck.  The  head 
may  grow  over  the  neck  like  a  mushroom,  a  fact  demonstrated  by  the 
x-ray,  and  regarded  by  Hofmeister  as  indicating  that  the  disease  occurs 


COXA    VARA. 


515 


in  the  cartilage  between  the  neck  and  head.     Generally  the  neck  is 

shortened   and   involuted   so  that   the  head   lies  directly   upon   the  lesser 

trochanter.    (Compare  Figs.  336  and  :>:>7.) 

The  cartilage  of  the  head  is  usually  intact,  exceptionally  destroyed 
in  spots.  Polished  and  hardened  surfaces  point  with  certainty  to 
arthritis  deformans.  Occasionally  the  hone  has  been  found  slightly 
compressible;  in  other  instances  abnormally  hard.  The  femur,  recently 
studied  by  Sndeek  and  Bahr  in  a  large  number  of  cases,  shows  a  visible 
ami  palpable  ridge  at  the  point  where  the  curvature  takes  place  in  the 
neck.    It  is  supposed  to  he  an  increased  deposit  of  hone  augmenting  tin 


Fig.  336. 


Fig.  337. 


Coxa  vara.     (Specimens  of  Hoffa's.) 

strength  of  the  tension  lamelhe.  If  this  augmentation  is  absolutely  or 
relatively  insufficient,  a  curvature  backward  and  downward  is  supposed 
to  take  place.  This  ridge  is  unquestionably  present,  but  its  significance 
is  disputed  by  Bahr,  who  regards  it  rather  as  a  point  of  attachment  for 
the  strong  fibres  of  the  capsule. 

Great  uncertainty  exists  at  the  present  time  as  to  the  actual  condition 
of  the  bone  in  coxa  vara.  Muller,  Hofmeister,  Lauenstein,  and  many 
others  assume  a  localized  late  rhachitis.  Kocher  assumes  a  special  form 
of  juvenile  osteomalacia.  No  evidence  is  given  for  the  view  of  a  late 
rhachitis,  the  conclusion  being  drawn  by  analogy  from  Mikulicz'  theory 
of  the  origin  of  genu  valgum  in  adolescence.  Kirmisson  and  Charpentier 
believe  that  there  is  usually  an  arthritis  deformans,  and  apparently  deny 


516  DISEASES  OF  THE  HIP. 

the  existence  of  a  particular  coxa  vara  adolescentium.  Kiister  assumes 
an  ostitis  fibrosa.  Whitman  conceives  that  there  is  merely  an  excessive 
increase  in  the  normal  process,  as  the  inclination  angle  is  always  dimin- 
ished toward  the  end  of  childhood.  The  author  thinks  that  in  coxa  vara 
adolescentium  the  affection  is  not  a  uniform  one,  but  that  a  number  of 
different  processes  may  produce  the  deformity  in  connection  with  the 
same  injurious  external  influences. 

As  to  these  external  causes,  there  is  no  question  as  to  the  action 
of  the  body-weight — that  is,  we  are  dealing  with  a  static  deformity. 
Kocher,  Manz,  and  Bahr  believe  that  if  the  bone  is  abnormally  pliant 
the  neck  may  be  bent  if  the  legs  are  habitually  held  spread  apart  and 
rotated  strongly  outward.  As  this  attitude  is  one  frequently  assumed 
by  those  engaged  in  agricultural  work,  especially  dairymen,  Kocher 
calls  coxa  vara  an  occupational  disease  of  adolescence.  The  increased 
material  observed  recently  proves,  however,  that  the  disease  occurs  in 
various  occupations  in  which  the  injurious  attitude  is  not  always  demon- 
strable. It  is  certain  that  in  a  relatively  large  number  of  cases  a  faulty 
disposition  of  the  weight  is  the  cause,  as,  for  example,  in  the  genu 
valgum  of  bakers  and  typesetters  and  the  flat-foot  of  waiters.  Stieda 
cites  the  frequency  of  a  lymphatic,  chlorotic  diathesis  in  the  patients 
concerned. 

Diagnosis. — The  diagnosis  is  usually  easy  if  the  history  and  local 
condition  are  compared  carefully;  nevertheless  there  are  cases  dependent 
upon  the  .r-rav.  Hofmeister  calls  attention  to  the  possibility  of  error 
unless  the  tube  is  placed  directly  over  the  hip  at  a  distance  of  about 
23  inches,  the  patient  being  in  the  abdominal  position  with  the  limb 
rotated  inward  slightly  or  straight. 

In  the  differential  diagnosis  the  forms  of  coxa  vara  following  rhachitis, 
osteomalacia,  ostitis  fibrosa,  osteomyelitis,  tuberculosis,  arthritis  defor- 
mans, and  traumatic  separation  of  the  epiphysis,  must  be  excluded.  The 
diagnosis  is  often  very  difficult.  In  rhachitis  there  are  changes  elsewhere 
in  the  skeleton.  In  arthritis  deformans  Maydl  believes  that  there  is  a 
difference  in  the  width  of  the  two  sides  of  the  pelvis  measured  from  the 
prominence  of  the  trochanter  to  the  middle  line,  the  affected  side  being 
shorter,  whereas  in  coxa  vara  the  distance  is  greater.  Curvature  of  the 
neck  following  a  non-purulent  inflammation  of  the  hip-joint  may  be  dis- 
tinguishable only  by  a  very  careful  history,  study  of  the  general  condi- 
tion and  the  .r-rav.  Congenital  or  acquired  dislocation  is  excluded  by 
the  history,  and  the  fact  that  the  head  lies  in  the  cavity  and  the  centre 
of  motion  of  the  joint  corresponds  clearly  to  the  cavity.  Fracture  of  the 
neck  or  separation  of  the  epiphysis  comes  in  question  only  after  trauma. 
Whitman,  Sprengel,  and  Hofmeister  have  shown  that  only  slight  trauma 
is  necessary,  however,  and  that  it  may  have  occurred  many  years 
previously. 

Treatment. — If  seen  early,  rest  with  continuous  traction,  massage, 
strengthening  diet,  and  the  administration  of  drugs  influencing  the  pro- 
duction of  bone  may  bring  about  a  complete  recovery.  Usually  the  case 
is  seen  after  considerable  deformity  has  developed;  even  then  the  above 


COXA    VARA.  517 

measures  may  effect  a  satisfactory  result,  although  the  deformity  per- 
sists. The  pain  due  to  the  abnormal  demands  made  upon  the  ligaments 
and  muscles,  analogous  to  that  of  the  so-called  inflammatory  flat-foot, 
almost  always  yields  to  traction  and  massage,  so  that  patients  who  even 
urge  operation  to  alleviate  the  pain  are  relieved  entirely  in  a  few  weeks 
and  considerably  improved.  Haver  claims  that  the  shortening  has  been 
decreased  by  extension.  Gymnastics  arc  particularly  valuable:  the 
author  strengthens  especially  the  abductors  by  active  and  passive  motion, 
and  has  the  patient  exercise  diligently  with  Krukenberg's  "Pendel- 
apparat." 

Operation  may  be  necessary  if  the  deformity  causes  considerable 
impairment  of  motion  and  the  latter  persists  after  the  pain  has  ceased. 
Simple  tenotomy  of  the  adductors  (Zehnder),  tenotomy  with  forcible 
correction  (Vulpius),  and  osteotomy  have  been  tried.  Kraske  prefers 
wedge-shaped  osteotomy  of  the  neck;  Budinger  does  a  linear  osteot- 
omy; Lauenstein  suggests  division  proximal  to  the  trochanter;  Miiller 
and  Hofmeister  favor  linear  subtrochanteric  osteotomy.  The  author 
would  recommend  oblique  subtrochanteric  osteotomy,  as  in  his  ex- 
perience it  has  proved  more  satisfactory  than  cuneiform  osteotomy 
of  the  neck.  On  account  of  the  shortness  of  the  neck  one  is  liable 
to  open  the  joint  in  operating  on  the  former  (Bardenheuer,  Xasse, 
Hofmeister),  so  that  the  condition  should  be  ascertained  previously  with 
the  x-ray. 

Mikulicz  claims  good  results  by  chiselling  off  the  highest  point  of 
the  curved  neck;  the  projection  is  supposed  to  form  the  chief  hindrance 
to  abduction  by  striking  against  the  upper  margin  of  the  cavity.  Resec- 
tion of  the  joint  is  best  for  the  severe  cases.  The  improvement  in  the 
gait  and  general  condition  in  the  majority  of  cases  of  resection  verify 
its  value.  (Miiller,  Hoffa,  Kocher,  Maydl,  Sprengel,  and  others.)  In  the 
case  which  the  author  resected,  the  shortening  was  reduced  from  2f  to 
1-f  inches.  The  importance  of  gymnastics  and  massage  after  the 
extension  is  removed  is  self-understood. 

Prognosis. — The  pain  in  the  acute  stage,  which  usually  keeps  the 
patient  in  bed,  finally  disappears  in  most  of  the  cases  or  is  brought  on 
only  by  overexertion,  so  that  change  of  occupation  is  rarely  necessary. 
This  stage  lasts  either  several  months  or  several  years;  exceptionally 
attacks  of  pain  occur  even  late  in  life.  In  regard  to  improvement  in  the 
faulty  position  of  the  limb,  first  the  flexion,  then  the  inward  rotation, 
and  finally  the  limitation  of  abduction  disappears.  The  amount  of 
improvement  to  be  expected  is  often  best  estimated  under  anaesthesia. 
As  in  flat-foot,  the  disability  may  depend  upon  muscular  spasm  and 
not  upon  anatomical  changes,  the  stiffness  disappearing  under  anaes- 
thesia. Naturally  one  must  exclude  atrophic  shrinkage  of  the  mus- 
cles, especially  of  the  adductors.  The  use  of  the  limb  increases  as 
the  muscular  resistance  diminishes.  Changes  also  probably  take  place 
in  the  bone — that  is,  as  the  head  is  gradually  absorbed,  a  new  joint  is 
formed  between  the  acetabulum  and  the  neck.  The  prognosis  in  general 
is  therefore  favorable. 


518  DISEASES  OF  THE  HIP. 

The  Remaining  Forms  of  Coxa  Vara. — Besides  coxa  vara  adoles- 
centium,  which  has  been  described  more  fully  on  account  of  its  practical 
importance,  there  are  a  number  of  other  forms  of  disease  which  may 
produce  a  varus  deformity  of  the  hip-joint.  A  series  of  individual 
observations  were  published  some  years  ago;  since  then,  more  recently, 
all  the  affections  concerned  have  been  classified  by  Charpentier,  de 
Quervain,  and  more  particularly  by  the  author's  assistants,  Alsberg 
and  Wagner. 

A  congenital  deformity  occurs  associated  with  severe  deformities  in 
other  joints.  (Kredel.)  The  cause  is  supposed  to  be  lack  of  space  in 
the  uterus.  Kirmisson  describes  a  hip-joint  in  a  young  child,  the  out- 
ward appearance  of  which  somewhat  suggested  coxa  vara,  but  in  which 
in  reality  the  deformity  was  due  to  a  short  posterior  capsular  wall  hold- 
ing the  limb  rotated  outward  strongly.  Zehnder  reports  a  case  of  sup- 
posed congenital  coxa  vara  which  is  very  doubtful.  The  congenital 
form  is  apparently  very  rare.  Congenital  dislocation  of  the  hip,  espe- 
cially if  of  long  standing,  may  produce  a  deformity  of  the  upper  end 
of  the  femur  which  after  reduction  may  hinder  abduction  and  require 
operation.  A  foetal  specimen  described  by  Wagner  proves  that  a  cur- 
vature of  the  neck  may  accompany  intrauterine  dislocation  of  the  hip. 

Coxa  vara  rhachitica  is  not  rare,  although  not  so  common  as  the 
rhachitic  deformities  elsewhere.  In  young  children  there  is  frequently 
an  habitual  outward  rotation  of  the  limb  without  impaired  abduction. 
(wSchede.)  It  is  not  unusual  to  find  the  trochanter  higher  than  normally 
and  abduction  considerably  limited.  In  the  majority  of  cases  therefore 
the  inclination  angle  of  the  neck  is  actually  smaller;  occasionally  the 
condition  may  be  simulated  by  curvature  of  the  shaft  just  below  the 
trochanter  (Kirmisson);  the  a;-ray  is  conclusive.  Kirmisson  and  Char- 
pentier, who  have  examined  numerous  rhachitic  skeletons,  state  that 
the  inclination  angle  of  the  neck  is  rarely  diminished  to  any  extent. 
Lauenstein  in  one  case  found  the  angle  diminished  on  one  side,  greatly 
increased  on  the  other.  The  relation  of  Goxa  vara  adolescentium  to 
rhachitis  is  still  undetermined.  The  deformity  if  slight  may  be  corrected 
like  other  rhachitic  deformities;  if  severe,  in  addition  to  general  treat- 
ment, subtrochanteric  osteotomy  may  be  beneficial,  as  the  author  can 
attest  from  operation  upon  a  bilateral  case. 

Osteomalacia  does  not  cause  coxa  vara  as  frequently  as  one  would 
suppose.  The  author  knows  of  only  two  authentic  cases,  one  of  Hof- 
meister's  and  another  of  Alsberg's.  Equally  uncommon  is  the  varus 
deformity  of  acute  osteomyelitis  (v.  Yolkmann,  Diesterweg,  Sehede, 
Stahl,  Oberst,  v.  Brans,  Honsell)  and  tuberculous  coxitis  (Kocher  and 
others).  A  case  of  ostitis  fibrosa  with  the  deformity,  reported  by 
Kiister,  is  a  pathological  rarity. 

Arthritis  deformans  frequently  causes  coxa  vara.  It  is  important, 
as  it  is  largely  responsible  for  the  early  impairment  of  abduction.  There 
is  a  certain  tendency  to  self-compensation  in  the  affection,  the  joint- 
surface  being  placed  as  obliquely  as  possible  so  that  even  if  the 
inclination  angle  is  greatly  diminished,  namely,  the  head  lowered,  the 


I  ML  AM  MATH  )S  OF  THE  Ii  URSJE  A  T  THE  Jill'.  5 1 9 

direction-angle  of  the  head  does  not  appear  to  be  decreased;  hence, 
there  is  no  actual  varus  position.  This  tendency  can  be  utilized  by 
abducting  the  Limb  continuously  and  subluxating  the  head  downward. 

Fracture  of  the  neck,  infraction,  or  separation  of  the  epiphysis  can 
produce  the  so-called  traumatic  coxa  vara.  1  )c  Quervain  reports  a  case 
of  coxa  vara  following  fracture  of  the  neck,  which  was  resected  success- 
fully by  Kocher.  Sudeck  and  Alsberg  have  shown  that  a  static  coxa 
vara  can  develop  if  strain  is  placed  too  soon  on  an  infraction  of  the 
neck;  the  inflexion  is  naturally  at  the  point  of  fracture.  From  the  works 
of  Whitman  and  Sprengel  it  is  known  that  separation  of  the  epiphysis 
is  not  uncommon  in  children  even  after  slight  trauma.  The  head  may 
become  reunited  in  a  false  position  by  bony  union,  with  loss  of  the 
epiphyseal  cartilage;  it  is  rotated  and  displaced  downward,  the  neck  is 
bent  backward,  the  limb  is  thus  adducted  and  rotated  outward.  The 
picture  clinically  and  with  the  a>ray  is  similar  to  that  of  coxa  vara  in 
adolescence. 

The  differential  diagnosis  is  especially  difficult  if  the  trauma  occurred 
several  years  previously.  Where  trauma  cannot  be  verified,  the  sudden 
onset,  pain  severe  at  first  but  disappearing  rapidly,  limitation  to  one 
side,  and  the  absence  of  deformities  elsewhere  speak  for  the  trau- 
matic origin.  The  disability  is  often  marked  ;  the  treatment  is  the 
same  as  that  of  the  adolescent  form. 


INFLAMMATION  OF  THE  BURS.E  AT  THE  HIP. 

Of  the  numerous  bursae  about  the  hip,  variously  estimated  by  Heineke 
as  14,  by  Synnestvedt  as  21,  the  most  important  are  the  iliac  and  deep 
trochanteric. 

The  iliac  or  subiliac  bursa  is  about  the  size  of  a  hen's  egg  in  adults, 
and  is  situated  beneath  the  iliopsoas  muscle  on  the  anterior  surface  of 
the  pubis,  below  and  to  the  outer  side  of  the  pubic  spine.  (Fig.  338.) 
It  lies  in  the  lacuna  musculorum  with  the  crural  nerve  to  the  outer  side 
of  the  sheath  of  the  femoral  vessels,  and  may  communicate  with  the 
hip-joint  or  be  separated  from  it  only  by  the  synovial  membrane.  In- 
flammation and  distention  of  the  bursa  may  therefore  affect  the  nerve. 

The  bursa  trochanterica  profunda  (bursa  aponeurotica,  or  glutei 
maximi,  or  gluteotrochanterica)  separates  the  gluteus  maximus  from 
the  great  trochanter,  is  rather  large,  simple  or  lobulated,  and  has  three 
thin  spots  in  the  wall — behind,  in  front,  and  below — through  which 
suppuration  may  perforate.  The  rare  bursa  trochanterica  subcutanea 
lies  over  the  great  trochanter  beneath  the  subcutaneous  tissue. 

The  bursa  glutei  medii  corresponds  to  the  position  of  the  attachment 
of  the  gluteus  medius  on  the  tip  and  outer  surface  of  the  great  trochanter. 
The  bursa  glutei  minimi,  corresponding  to  the  insertion  of  the  same 
muscle,  lies  on  the  inner  surface  of  the  tip  of  the  trochanter.  The  bursa 
tendinis  obiuratoris  interni  lies  at  the  sciatic  notch  beneath  the  obturator 
internus  as  it  emerges  from  the  pelvis.     A  bursa   vaginalis  obturatoris 


520 


DISEASES  OF  THE  HIP. 


interni  is  found  infrequently  between  the  tendons  of  the  obturator 
interims  and  the  gemelli.  A  bursa  subcutanea  is  often  found  in  the 
connective  tissue  over  the  anterior  superior  spine.  A  bursa  iliaca 
posteriori  is  frequently  found  between  the  posterior  ilac  spine  and  the 
fascia.  The  bursa  glut  cot uberosa  corresponds  to  the  point  where  the 
gluteus  maximus  passes  over  the  tuber  ischii. 

As  in  general,  acute,  chronic,  primary,  and  secondary  inflammation 
of  the  bursa?  may  be  distinguished.  The  secondary  inflammations, 
especially  of  the  iliac  bursa,  are  important  as  the  process  may  spread 
through  a  direct  communication  or  indirectly  into  the  joint.  An  abscess 
from  the  bone  or  joint  may  spread  outward  through  the  bursa  or  from 


Fig.  338. 


Rectus  femoris. 


"Bursa  of  1he:m 
gluteus  mi  dins. 


Bursa  of  the 
gluteus  maximus. 
(B.    troehanterica 

profunda.) 
Gluteus  maxim  us.— 


Bursa  subiliaca 

superior. 


Bursa  subiliaca 

inferior. 


—Ilcopsoas. 


Vastus  c.i  tenuis. 

Bursse  in  the  hip. 

the  opposite  direction  (spondylitis  or  pelvic  abscess)  into  the  joint. 
Primary  bursitis,  acute  or  chronic,  serous  or  purulent,  may  follow 
wounds  or  contusions.  Simple  hygroma  is  most  common  On  account 
of  its  exposed  position  the  trochanteric  bursa  can  be  the  scat  of  a  hema- 
toma. The  most  frequent  cause  of  bursitis  is  trauma,  but  the  inflam- 
mation may  be  transmitted  or  follow  an  infectious  disease  (typhoid, 
septicaemia,  gonorrhoea,  syphilis).  According  to  Petit,  trauma  is  the 
cause  in  57  per  cent,  of  all  cases,  rheumatism  in  15  per  cent.,  icterus, 
cold,  and  puerperal  fever  each  in  2  per  cent.,  and  in  32  per  cent,  the 
cause  is  unknown. 

Symptoms. — The  inflammation  at  the  onset  is  manifested  by  swelling 
and  more  or  less  pain,  the  swelling  corresponding  in  general  to  the 


INFLAMMATION  OF  THE  BURSJS  AT  THE  1111'.  521 

position  of  the  bursa,  although  it  can  be  so  extensive  that  it  may  be 
difficult  to  determine  the  point  of  origin.  Cases  of  subiliac  bursitis  have 
been  seen  in  which  the  tumor  extended  from  Poupart's  ligament  to  the 
middle  of  the  thigh;  similarly  one  of  the  bursa  trochanterica  profunda 
extending  from  the  sacro-iliac  synchondrosis  almost  to  the  inguinal 
vessels. 

BURSITIS  of  the  subiliac  bursa  may  give  multiple  swellings,  for  ex- 
ample, on  either  side  of  the  iliopsoas  with  through-fluctuation.  Fluctua- 
tion may  be  absent  if  the  wall  is  thick  or  greatly  distended;  in  the  latter 
case  it^may  be  mistaken  for  a  solid  tumor.  Fluctuation  otherwise  unob- 
tainable, may  be  elicited  by  flexing  the  thigh.  Transparency  has  been 
seen.  The  surface  of  the  tumor  is  smooth.  If  dealing  with  a  hygroma, 
the  overlying  skin  and  the  tumor  are  independently  movable.  If  the 
tumor  presses  upon  the  crural  nerve,  there  may  be  shooting  pains  radia- 
ting to  the  knee.  Compression  of  the  vessels  and  venous  thrombosis 
are  very  rare. 

The  position  of  the  limb  is  that  causing  the  least  pain  and  pressure 
upon  the  tumor,  namely,  flexion,  abduction,  and  outward  rotation;  less 
frequently  abduction  and  inward  rotation.  The  corresponding  muscles 
are  contracted;  motion  at  the  hip-joint  is  limited  but  free  under  anaes- 
thesia. The  mobility  is  important  in  the  diagnosis  against  coxitis,  as  the 
latter  may  produce  the  same  anomalous  position.  One  thinks  especially 
of  coxitis  if  there  is  a  suppurative  bursitis  with  perforation  or  fistulas. 
Aside  from  the  differential  diagnosis  already  given  under  coxitis,  flexion 
is  less  pronounced  in  bursitis.  The  fact  that  the  position  of  the  tro- 
chanter and  the  length  of  the  limb  are  normal  excludes  all  the  affections 
in  which  the  trochanter  is  elevated  or  the  length  of  the  limb  changed. 
Echinococcus  is  excluded  by  the  character  of  the  contents  of  the  bursa. 
Femoral  hernia  is  usually  excluded  by  the  situation,  direction,  contents, 
and  consistence  of  the  tumor. 

Bursitis  of  the  bursa  trochanterica  profunda  gives  a  swelling 
above  the  trochanter  on  the  outer  side  of  the  femur.  If  extensive,  the 
gluteal  fold  may  be  obliterated.  The  tumor  may  be  divided  ij^to  two  parts 
by  the  muscles.  The  limb  is  flexed,  abducted,  and  rotated  outward,  as 
in  the  iliac  form,  from  the  patient's  effort  to  relieve  the  pressure  of  the 
glutei.  The  differential  diagnosis  from  coxitis  is  as  above;  pressure  at  the 
trochanter  is  painful  in  both  affections,  but  the  extreme  sensitiveness  in 
front  of  and  behind  the  joint  in  coxitis  is  absent  in  bursitis.  The  gluteal 
fold  may  be  obliterated,  and  if  suppuration  occurs,  the  swelling  may 
lie  where  one  often  meets  with  superficial  abscesses  from  the  hip-joint, 
namely,  behind  the  trochanter.  Fistulas  often  present  in  the  same  spot  in 
both  affections.  In  coxitis  walking  is  often  intensely  painful,  the 
reverse  in  bursitis.  A  blow  upon  the  heel  is  painful  in  coxitis  but  not 
in  bursitis.  It  may  be  difficult  to  exclude  an  ostitis  of  the  trochanter,  as 
pain,  redness,  and  swelling  occur  in  both  affections;  furthermore,  the 
two  affections  may  be  coexistent,  the  one  primary,  the  other  secondary. 

Bursitis  of  the  superficial  trochanteric  bursa  is  distinguished 
from  inflammation  of  the  deep  bursa,  according  to  Duvelius,  by  the  fact 


522  DISEASES  OF  THE  HIP. 

that  the  tumor  lies  directly  beneath  the  skin,  and  is  not  displaced  by  move- 
ments of  the  limb,  while  the  swelling  of  the  deep  bursa  slides  backward 
in  flexing  the  limb.  According  to  Berend,  the  subcutaneous  swelling  is 
oval  in  the  long  axis  of  the  limb,  whereas  the  subaponeurotic  swelling 
is  a  narrower,  longer  ellipsoid.  The  mobility  of  the  tumor  is  limited 
by  its  position.  The  -kin  is  usually  movable  over  it  and  normal;  in 
the  suppurative  form  it  is  infiltrated.  The  growth  of  the  trochanteric 
hygroma  is  usually  gradual,  seldom  rapid.  The  sciatic  nerve  is  endan- 
gered if  the  tumor  extends  backward;  cases  are  known  in  which  it  was 
infiltrated  and  displaced. 

A  few  cases  of  inflammation  of  the  other  bursas  have  been  reported. 
Knowing  the  position  of  these  bursas,  inflammation  of  the  same  may 
be  recognized  by  relaxing  the  muscles,  pressing  upon  the  bursa,  and 
eliciting  fluctuation,  by  palpating  the  surface,  by  aspirating,  and  by  the 
history.  Hygroma  of  the  bursa  on  the  tuber  ischii  occurs,  according 
to  Konig,  especially  in  individuals  who  do  hard  manual  labor  while 
sitting.     The  .'*-ray  is  valuable  in  excluding  affections  of  the  bone. 

Prognosis. — The  prognosis  of  bursitis  as  such  is  usually  good  if  treat- 

,t  is  begun  promptly  before  a  neighboring  joint  is  involved.    In  spite 

of  radical  operation  recurrence  is  occasionally  observed,  a  new  bursa 

forming   and    becoming   inflamed    if   exposed    to    the    same   injurious 

influences. 

Treatment. — For  hygroma  compression  combined  with  applications  of 
tincture  of  iodine,  inunction  of  blue  ointment,  or  massage  is  often  suffi- 
cient; even  poultices  or  compresses  of  lead-water  may  be  beneficial.  If 
unsuccessful,  aspiration  followed  by  compression  is  useful.  After  aspira- 
ting one  mav  inject  iodine,  according  to  Velpeau.  to  excite  adhesions  and 
obliteration  of  the  cavity,  except  when  the  walls  are  very  thick,  or 
there  are  multiple  bursas,  or  it  is  suspected  that  the  bursa  communicates 
with  a  joint.  It  may  be  necessary  to  incise  or  enucleate  the  tumor. 
Suppuration  demands  immediate  incision  and  preferably  removal  of  the 
sac;  or  if  too  adherent,  thorough  scraping  with  a  -harp  spoon.  The 
wound  is  drained  or  tamponed. 


INFLAMMATIONS   OF  THE  INGUINAL  GLANDS. 

Inguinal  adenitis  is  a  very  common  occurrence.  The  so-called  indolent 
bubo  of  syphilis  requires  no  special  treatment.  Painful  inflammation 
of  the  glands  occurs  with  inflammation  of  the  genital.-,  the  inguinal 
region,  and  the  lower  extremities,  the  transmission  of  the  inflammatory 
product  through  the  lymphatics  to  the  glands  producing  swelling  and 
pain  in  the  latter.  The  path  of  the  inflammation  is  not  always  shown 
by  a  visible  lymphangitis.  For  example,  after  small  abrasions  on  the 
>r  non-aseptic  excision  of  bunion-,  an  inguinal  adenitis  sometimes 
develops  without  the  characteristic,  red,  painful  lines  upon  the  limb. 
When  the  gland-  are  swollen  the  genital-  should  be  examined  for 
specific  infection   in  the  absence  of   other   evidence.     A    primary  bal- 


IXFLAMMATIOXS  OF  THE  INGUINAL  GLANDS  523 

anitis  due  to  ulceration  may  be  the  cause.  The  source  of  infection, 
a>,  for  example,  in  phlegmon  or  erysipelas,  requires  appropriate  treat- 
ment. Severe  abscesses  frequently  develop  from  inflammation  of 
Etosenmuller's   glands,  situated    between  Poupart's  ligament   and   the 

horizontal  ramus.    They  should  be  excised  radically. 

Treatment. — If  the  original  source  of  infection  is  removed,  large,  even 
softened  glands  disappear  entirely  with  rest  and  application  of  cold, 
pressure,  iodine,  or  blue  ointment.  If  purulent,  the  pus  may  be  aspirated. 
But  if  the  swelling  invades  the  adjacent  tissues,  the  skin  becomes  red 
and  perforation  is  imminent:  if  only  one  gland  is  affected,  it  is  incised;  if 
the  entire  chain,  it  is  best  to  remove  them  radically,  avoiding  the  large 
vessels.  If  diseased  tissue  is  left,  protracted  suppuration  and  fistula- 
may  result.  The  wound  should  be  packed  with  iodoform  gauze  and 
partially  closed.  Chronic  oedema,  sometimes  swelling  of  the  limb 
similar  to  elephantiasis,  is  occasionally  observed  after  total  extirpation. 

Welander  and  Spietschka  have  obtained  good  results  by  injecting 
hydrargyrum  benzoicum  oxydatum  in  non-specific  adenitis;  its  use  in 
the  Berlin  clinic  is  reported  favorably  by  Thorn.  A  1  per  cent,  solution 
is  employed  even  if  suppuration  is  well  advanced,  as  the  drug  checks 
the  process  by  causing  the  small  suppurating  foci  to  become  rapidly 
confluent  and  by  destroying  the  bacteria.  Thorn  reports  26  good  results 
in  30  cases  after  one  injection  of  4  or  5  c.c.  Lang's  recent  method 
consists  in  first  injecting  a  1  per  cent,  silver  nitrate  solution  into  all  the 
pockets  of  the  abscess  through  one  or  two  small  incisions,  then  drawing 
off  the  contents  and  covering  the  wound.  This  is  repeated  every  two 
days  till  the  contents  become  serous,  then  pressure  is  applied. 


CHAPTER  XXV. 

OPERATIONS  AT  THE  HIP. 
RESECTION  OF   THE  HIP-JOINT. 

Resection  of  the  hip-joint  was  first  recommended  by  Charles  White 
in  1769,  after  experimenting  on  the  cadaver,  and  first  performed  by 
Anthonv  White  in  1821,  through  a  curved  incision  above  the  trochanter. 
The  method  was  named  later  after  Velpeau,  as  he  adopted  it  and 
recommended  it  widely.  Jager,  Roux,  Textor,  and  Percy  formed  three- 
and  four-cornered  flaps;  Sedillot  made  a  curved  flap  with  the  base 
below. 

Subperiosteal  resection  was  developed  chiefly  by  v.  Langenbeck.  (Fig. 
339.)  With  the  patient  in  the  lateral  position  and  the  thigh  flexed, 
an  incision  4  or  5  inches  long  is  made  from  directly  over  the  middle  of 
the  trochanter  toward  the  posterior  spine  of  the  ilium.  The  fascia  is 
split,  the  glutei  divided  in  the  long  axis  of  the  neck,  all  muscular 
attachments  lifted  subperiosteally  from  the  trochanter  while  rotating 
the  limb  appropriately  inward  and  outward,  the  capsule  is  divided,  the 
ligamentum  teres  cut  through  with  the  limb  flexed,  adducted,  and 
rotated  inward  forcibly,  and  the  head  dislocated  and  sawed  or  chiselled 
off.  The  method  has  undergone  many  modifications;  Konig  recom- 
mends saving  the  muscular  attachments  on  the  trochanter  by  chiselling 
off  a  front  and  a  back  bone-flap  from  the  surface  of  the  trochanter,  the 
wedge-shaped  piece  of  the  trochanter  left  beneath  being  chiselled  off 
squarely. 

Kocher  makes  a  curved  incision  (Fig.  340)  beginning  at  the  base  of  the 
posterior  surface  of  the  great  trochanter,  from  this  point  curving  down- 
ward and  obliquely  upward  toward  the  middle  line  behind  in  the  direc- 
tion of  the  fibres  of  the  gluteus  maximus.  The  fascia  of  the  gluteus 
maximus  on  the  outer  surface  of  the  trochanter  is  split  and  the  attach- 
ment of  the  gluteus  medius  and  the  periosteum  of  the  trochanter  exposed. 
The  fibres  of  the  gluteus  maximus  arc  separated,  or  better  the  upper 
border  of  the  muscle  detached  and  drawn  down.  Between  the  lower 
border  of  the  gluteus  medius  and  the  tendon  of  the  piriformis  the  ten- 
dinous attachments  arc  separated  forward  from  the  trochanter  to  the 
subtrochanteric  line,  the  capsule  divided,  the  tendinous  attachments 
separated  subperiosteally  backward  on  the  trochanter,  and  the  bone 
exposed.     The  further  steps  are  the  same  as  in  v.  Langenbeck's  method. 

Tiling  incises  at  the  anterior  border  of  the  trochanter,  chisels  off 
the  entire  trochanter,  and  draws  it  backward,  separates  the  capsule  in 
front,  removes  the  lesser  trochanter,  dislocates  the  head,  and  cleans  out 
(  524  ) 


RESECTION  OF  Till:  HIP  JOINT 


525 


the  joint  cavity.  Sprengel  gives  a  useful  incision  to  expose  the  entire 
joint  and  the  surrounding  parts  in  old  cases  of  extensive  suppuration. 
1'1";  Mlh\  lhe  mcision  runs  along  the  posterior  edge  of  the  tensor 
fascue  and  curves  backward  at  the  anterior-superior  spine  along  the 
outer  border  ot  the  crest  of  the  ilium  to  the  posterior-superior  ipine- 
along  the  crest  ..  u  carried  down  to  the  bone.  The  large  flap  of  skin' 
muscles,  and  periosteum  is  turned  backward  and  downward  and  the 
region  of  the  joint  freely  exposed.  At  the  close  of  the  operation  the 
Hap  is  sutured  in  place  and  the  wound  drain,,!.  Sprengel's  incision  is 
tne  transition  to  the  incision  opening  the  joint  from  in  from. 


Tig.  339. 


Fig. 


Spmigd 


T.  Langenbeck's  incision  for  resection  of 
the  hip-joint. 


Sprengel' 


and  Kocher's  incisions  for  resection 

of  the  hip-joint. 


Roser  recommends  an  anterior  transverse  incision  in  the  direction  of 
the  neck  for  cases  in  which  the  limb  is  extended  and  abducted.  Huter 
makes  an  oblique  incision  (Fig,  341)  beginning  midway  between  the 
anterior-superior  spine  and  the  trochanter  and  running  downward 
along  the  outer  border  of  the  sartorius.  The  vastus  externus  is  divided 
and  the  bone  exposed;  at  the  lower  angle  of  the  incision  the  external 
circumflex  artery  should  be  protected.  Liicke  and  Schede  use  the  ante- 
rior longitudinal  incision  for  removing  the  head  after  injury.  (Fig.  342.  | 
It  begins  below  and  \  inch  to  the  inner  side  of  the  anterior-superior 
spine,  and  runs  from  4  to  5  inches  directly  downward;  the  inner  border 
of  the  sartorius  and  the  rectus  are  exposed  and  the  muscles  retracted 


526 


OPERATIONS  AT  THE  HIP. 


outward;  the  dissection  is  carried  bluntly  to  the  outer  border  of  the 
psoas  and  the  muscles  drawn  inward.  The  thigh  is  then  flexed,  abducted 
and  rotated  outward,  the  capsule  opened  freely,  the  neck  exposed  and 
sawed  through.  The  cotyloid  ligament  and  teres  ligament  are  divided 
and  the  head  protruded.  If  sawed  off,  the  head  can  be  easily  scooped 
out  with  a  Willemer  or  Looker  spoon-elevator.  Konig  chisels  off  the 
upper  posterior  margin  of  the  acetabulum. 

In  resecting  for  tuberculosis  all  infected  tissue  is  thoroughly  removed 
and  the  cavity  cleaned  out  with  the  chisel.  It  will  seldom  be  necessary 
to  remove  the  entire  acetabulum  as  done  by  Bardenheuer  and  Schmidt. 
The  after-treatment  is  much  disputed:  the  author  does  not  recommend 
primary  suture  with  or  without  drainage;  recovery  has  always  been 
uneventful  if  the  wound  was  dusted  with  iodoform  and  tamponed  with 
iodoform  gauze.     Secondary  suture  is  superfluous.     Suture,  especially 


Fig.  341. 


Fig.  342. 


Hiiter'^  incision. 


I.ucke  and  Schede's  incision. 


primary,  frequently  causes  retention  and  subsequent  protracted  pain, 
fever,  and  suppuration.  An  aseptic  dressing  is  placed  over  the  wound 
and  the  edges  approximated  by  a  roller  bandage.  An  extension  splint 
can  then  be  applied,  or,  better,  the  limb  is  abducted  as  in  the  extension 
splint,  and  a  plaster  splint  put  on,  including  the  affected  limb  and  the 
other  thigh,  the  two  thigh  splints  being  united  by  a  cross-piece  to  give 
stability.  Sehede's  table  is  most  useful  for  this  purpose,  as  the  limb 
is  most  easily  extended  by  its  screw  appliance.  If  recovery  is  uninter- 
rupted, the  dressing  is  left  from  8  to  10  days  and  then  renewed  through 
a  large  fenestrum  cut  in  the  plaster;  later  the  wound  may  be  drawn 
together  with  strips  of  zinc  plaster.  The  author  allows  his  patients  to 
get  up  in  the  plaster  splint  in  from  two  to  three  weeks  and  go  about  in  a 
walking  chair.  Even  if  the  extension  treatment  has  been  employed 
without  a  plaster  splint,  the  author  recommends  that  a  well-fitting 
plaster  splint  be  applied  in  about  four  or  five  weeks  and  the  patient 


.  1  MI' I TTA  TION  A  T  THE  MP- JOINT.  r,27 

allowed  to  be  about.     Taylor's  apparatus  is  apt  to  produce  an  adduction 
position. 

A  movable  joint  stable  enough  to  carry  the  body  is  desirable,  but  not 
a  loose  joint.  Quite  a  number  of  subsequently  examined  specimens  of 
subperiosteal  resection  are  reported  in  which  a  head  was  formed  fairly 
well,  either  from  the  remaining  portion  of  the  neck  or  by  a  new  growth 
at  the  lesser  trochanter,  and  even  covered  with  cartilage.  (Kuster,  Israel, 
Sack,  Schede,  Rose,  Oilier.)  A  tendency  to  stiffness  should  not  he 
combated  too  vigorously,  but  rather  aided  by  immobilizing  the  limb 
slightly  flexed  and  abducted,  for  a  hip  ankylosed  in  flexion  and 
abduction  is  very  useful  and  desirable. 


AMPUTATION  AT  THE  HIP-JOINT. 

The  so-called  transfixion  method  formerly  employed  to  obviate  the 
danger  of  bleeding  is  not  necessary  with  the  present  teehnic  of  con- 
trolling hemorrhage.  Verneuil  and  Rose  remove  the  thigh  like  a  tumor, 
dissecting  by  layers  and  double  ligating  all  large  vessels  as  met.  The 
method  is  equally  commendable  for  tumors  about  the  hip-joint,  as  the 
soft  parts  can  usually  be  saved  only  partially.  If  possible,  the  incision 
is  made  so  that  the  femoral  artery  and  vein  can  be  ligated  at  the  outset, 
namely,  through  an  anterior  oval  incision  with  the  angle  at  about  the 
middle  of  Poupart's  ligament.  To  prevent  loss  of  blood,  Riedel  advises 
ligation  of  the  femoral  vein  at  the  close  of  the  operation,  not  with  the 
artery  at  the  beginning.  Larrey  recommended  preliminary  ligation  of 
the  femoral  artery  and  vein  to  diminish  the  loss  of  blood,  but  this  has 
no  influence  upon  the  not  inconsiderable  bleeding  from  the  branches  of 
the  internal  iliac,  obturators,  and  inferior  and  superior  gluteals,  or  from 
the  profunda  if  it  is  given  off  above  the  point  of  ligation. 

Biinger  was  the  first  to  ligate  the  common  iliac.  Later  Davy  com- 
pressed it  by  means  of  a  rod  in  the  rectum.  Trendelenburg  recom- 
mended digital  compression  of  the  external  iliac  vein  in  addition  to  ligation 
of  the  common  iliac  artery.  Rose  ligated  the  common  and  internal  iliac 
arteries  and  the  external  iliac  vein ;  the  bleeding  was  slight,  v.  Esmarch 
proposed  ligation  of  the  common  iliac  vein  and  artery  in  difficult  cases. 
As  there  was  danger  of  partial  necrosis  of  the  flaps  after  ligation  of  the 
common  iliac  artery,  especially  the  artery  and  vein,  Schonborn  advised 
temporary  ligation  of  the  common  iliac  artery.  Braun  compressed  the 
internal  iliac  artery  with  the  finger  after  ligating  the  external  iliac  artery 
ana  vein.  MeBurney  proposed  digital  compression  of  the  common 
iliac  through  an  incision  at  the  inner  side  of  the  anterior-superior  spine. 
The  aorta  has  often  been  compressed  in  thin  subjects,  v.  Esmarch 
invented  a  compressor  to  protect  the  intestines  from  being  bruised. 

The  preservation  of  the  soft  parts,  especially  the  muscles,  is  of  the 
greatest  importance  for  the  application  of  a  prothesis.  If  the  soft  parts 
about  the  hip-joint  cannot  be  saved,  the  large  vessels  can  be  ligated  pre- 
viously by  one  of  the  above  methods  and  the  amputation  made  almost 


528 


OPERA  TI0N8  A  T  THE  HIP. 


bloodless;  an  anterior  and  posterior  flap  are  preferable.  If  the  soft  parts 
about  the  hip  can  he  saved,  high  amputation  is  first  performed  and  thru 
the  head  removed  svbperiosteaUy.  (Fig.  .'>4o.  I  This  method  was  first  used 
by  Vetch  and  Ravaton,  and  was  especially  recommended  by  v.  Yolk- 
mann:  The  limh  is  first  elevated,  an  Esmarch  is  then  applied  and  tied 
firmly  at  the  groin  with  a  figure-of-8  turn  around  the  pelvis  to  prevent 
slipping.     Various  complicated  methods,  mostly  unnecessary,  to  prevent 


Fig.  343. 


Fig.  344. 


Kot  i  a -amputation  method. 

slipping  are  given  by  Trendelenburg, 

Wyeth,  and  Senn.  A  circular  in- 
cision is  then  made  6  inches  below 
the  tip  of  the  great  trochanter,  all 
vessels  are  ligated,  the  femur  ampu- 
tated, and  the.  Esmarch  removed;  the 
soft  parts  are  then  divided  longitudi- 
nally down  to  the  bone  on  the  outer 
side  of  the  femur,  the  periosteum  lifted 
off  with  the  elevator  and  dissected  r>ff 
with  the  knife  at  the  linea  aspera 
externa  and  at  the  trochanters;  the 
stump  is  then  covered  with  gauze,  flexed,  abducted,  and  rotated  in- 
ward with  the  left  hand,  the  capsule  incised  along  its  back  lower  mar- 
gin, the  cotyloid  ligament  cut  through,  the  head  dislocated,  and  the 
ligaments  and  capsule  divided  in  front.  Franke  and  Quenu,  instead 
of  removing  the  head,  proposed  to  chisel  it  off  at  the  neck  and  leave 
it.     It  was  supposed  to  hasten  recovery  and  improve  the  stumo. 


Incisions  for  amputation  and  exarticulation 
of  the  hip.      (v.  Winiwarter.) 


. i  MI'UTATION  A T  THE  HIP-JOINT.  529 

Ktx-hcr'x  " rc.s<<'iii)ii-amj>nt<iii<>n"  method  was  employed  by  bim  in  9 
cases  with  excellent  results.  (Fig.  344.)  The  incision  is  made  the  same 
as  For  resection;  he  then  dislocates  the  head  and  separates  the  soft  parts 
downward  from  the  great  trochanter  in  front  and  from  the  lesser  tro- 
chanter behind.  The  attachment  of  the  iliopsoas  on  the  latter  is  divided. 
After  appropriate  ligation  of  bleeding  points  the  limb  is  suspended  ver- 
tically and  a  broad  Esmarch  tourniquet  applied  in  a  figure-of-8  around 
the  highest  part  of  the  thigh  and  pelvis,  the  cross  being  behind  and 
above  the  great  trochanter.  High  amputation  follows  with  a  circular 
or  oval  incision,  or  with  two  short  flaps,  according  to  the  amount  of  skin 
available;  the  skin  is  retracted  and  the  muscles  cut  through  smoothly 
to  the  bone.  The  covering  should  always  be  ample.  After  incising 
the  periosteum  it  is  lifted  off  bluntly  from  below  upward  and  dissected 
off  at  the  linea  aspera.  The  bone  is  then  sawed  through,  the  femoral 
artery  and  vein,  profunda  artery  and  vein,  saphenous  vein,  and  all  small 
vessels  ligated  and  the  tourniquet  removed.  The  stump  is  then  freed 
from  all  attachments  subperiosteal^  and  removed  by  twisting. 

The  after-treatment  is  relatively  simple.  The  flaps  are  sutured, 
drains  placed  at  the  proper  points  or  a  strip  of  gauze  introduced.  The 
prothesis  is  not  made  until  cicatrization  is  complete. 

The  mortality  of  hip  amputation  was  70  per  cent,  in  the  preantiseptic 
period  (Liming),  more  recently  29  per  cent.  (Coronat),  and  even  as  low 
as  13  per  cent.  (Riedel). 


Vol.  Ill  —34 


DEFORMITIES,  INJURIES,  AND  DISEASES  OF  THE 

THIGH. 


CHAPTER  XXVI. 

DEFORMITIES  OF  THE  THIGH. 

Deformity  Due  to  Rhachitis. — The  deformity  of  rhachitis  is  usually 
a  curvature  convex  forward  and  outward,  that  of  fracture  with  malunion, 
an  inflexion  (angular  deformity)  forward  and  outward. 

Treatment. — Manual  correction  generally  accomplishes  little  in  either 
case,  osteoclasis  or  osteotomy  usually  being  necessary.  Lorenz  suggests 
combining  open  division  of  the  contracted  soft  parts  with  one  of  the 
latter  procedures.  The  limb  is  then  immobilized,  strongly  abducted. 
The  best  results  are  obtained  by  not  trying  to  overcome  the  abduction 
before  six  months  or  a  year. 

Phocomelia. — Phocomelia,  namely,  partial  or  complete  absence  of 
the  thigh,  is  a  very  rare  malformation.  According  to  Grisson,  Lange, 
Lotheissen,  Joachimsthal,  Reiner,  Blenke,  and  Drehmann,  four  varieties 
are  distinguishable:  1.  Shortening  of  the  femur  with  coxa  vara  or 
congenital  dislocation  of  the  hip.  2.  Division  of  the  femur  into  several 
pieces;  the  lower  end,  head,  and  trochanter  are  present  and  isolated. 
3.  The  same  as  2,  but  the  lower  epiphysis  is  united  to  the  tibia.  4.  The 
shaft  is  very  short,  the  hi])  and  knee-joint  being  normal. 

Treatment. — The  treatment  consists  in  applying  an  appropriate 
prothesis.     (Drehmann.) 

Maldevelopment  of  the  Lower  Epiphysis. — The  deformity  due  to 
maldevelopment  of  the  lower  epiphysis  is  illustrated  by  a  case  of  Nico- 
ladoni's:  "The  left  limb  is  short  and  flexed  at  the  knee.  Flexion  can 
be  exaggerated  till  the  calf  sinks  deeply  into  the  well-developed  muscles 
of  the  thigh.  Extension  is  limited  to  98  degrees,  motion  within  the 
limit  being  strong  and  active.  The  knee-joint  is  apparently  normal; 
the  muscles  or^the  thigh,  leg,  and  foot  are  apparently  as  strong  as  those 
of  the  other  limb.  The  thigh  and  leg  are  both  shortened;  the  tibia  is 
curved,  concave  inward,  chiefly  at  the  spine;  the  head  of  the  fibula  lies 
about  an  inch  higher  than  normally.  The  arrested  development  was 
due  to  trauma  in  childhood  affecting  the  lower  epiphysis  of  the  femur 
and  the  upper  epiphysis  of  the  tibia.  Walking  was  facilitated  by  a 
10-inch  stilt  on  the  sole  of  the  shoe." 

Deformity  of  the  Lower  End  of  the  Femur. — Konig  and  Braun 
have  recently  called  attention  to  a  peculiar  curvature  of  the  lower  end 
(530) 


DEFORMITIES  OF  THE  THIGH.  531 

of  the  femur,  convex  forward  above  the  knee-joint.  This  developed 
within  one  or  two  years,  and  followed  a  flexion  contracture  at  the  knee, 
which  in  turn  had  developed  six  to  ten  years  after  the  onset  of  the 
primary  disease  of  the  knee-joint,  usually  tuberculosis.  The  lower  end 
of  the  femur  was  abnormally  soft.  The  curvature  was  evidently  due  to 
changes  in  the  epiphyseal  line  and  in  the  disposition  of  weight,  for  the 
forces  which,  as  a  rule,  produce  a  genu  valgum  with  the  knee  extended, 
must  necessarily  product4  a  curvature  of  the  femur  in  the  sagittal  plane 
when  the  limb  is  flexed. 

Treatment.  -The  use  of  the  limb  can  be  restored  by  an  intraepiphyseal 
resection  of  the  joint;  to  this  Konig  adds  osteotomy  of  the  femur. 

The  deformities  due  to  osteomyelitis  will  be  discussed  later. 


CHAPTER   XXVII. 

INJURIES  OF  THE  THIGH. 
INJURIES  OF  THE  VESSELS  OF  THE  THIGH. 

By  reason  of  their  suoerficial  position  the  vessels  of  the  inguinal 
region  are  greatly  exposed  to  external  injuries.  So  we  meet  with  stab- 
wounds,  incised,  puncture,  lacerated,  and  shot-wounds.  The  femoral 
artery  may  be  injured  alone,  either  the  main  trunk  or  one  of  its 
branches,  or  simultaneously  with  the  vein.  In  fractures  by  direct  vio- 
lence splinters  of  bone  may  injure  the  vessels. 

The  brachial  is  the  artery  most  frequently  affected  alone,  then  the 
femoral.  The  danger  of  fatal  hemorrhage  increases  with  the  size  of 
the  wound  in  the  artery.  The  bleeding  from  slight  wounds  of  the  wall 
is  checked  by  coagulation  or  by  the  "wound  canal"  becoming  shifted, 
as  happens  occasionally  in  puncture  and  shot-wounds.  An  imprudent 
movement  of  the  arm  may  start  up  fatal  hemorrhage,  as  is  often  seen 
upon  the  battlefield.  If  bright-red  blood  spurts  from  the  wound  and 
the  opening  in  the  artery  can  be  seen,  the  diagnosis  is  simple.  If  the 
injured  artery  is  not  visible,  the  diagnosis  may  be  difficult.  The  situa- 
tion of  the  wound  and  the  cessation  of  the  pulse  in  the  affected  limb 
are  often  deceptive  if  the  wound  is  oblique  and  the  pulselessness  is  from 
loss  of  blood.  It  is  always  important  to  compare  the  pulse  in  both 
limbs,  although  rapid  dilatation  of  the  collaterals  can  occasionally  give 
a  fuller  pulse  in  the  injured  limb.  v.Wahl  gives  as  a  diagnostic  symptom 
of  partial  division  of  the  artery  a  harsh,  blowing  murmur  synchronous 
with  the  pulse — audible  at  the  point  of  injury. 

If  the  femoral  vein  or  one  of  its  larger  branches  is  injured,  dark-red 
blood  flows  slowly  but  steadily.  Dark  blood  spouting  in  a  large  stream 
during  forced  expiration  also  indicates  injury  of  the  principal  vein. 
Hemorrhage  from  the  venous  branches  often  stops  spontaneously  or  with 
temporary  pressure,  while  hemorrhage  from  the  main  trunk  is  much  more 
dangerous  and  usually  requires  operation.  Wounds  of  the  saphenous 
vein  are  of  slight  significance;  pressure  usually  checks  the  hemorrhage. 

Treatment. — The  first  aid  in  wounds  of  the  large  vessels  is  strong 
digital  pressure  in  the  wound  or  against  the  pubis  at  Poupart's  ligament. 
Later,  ligation  or  suture  of  the  vein  or  artery  is  indicated.  Ligation 
should  be  at  the  point  of  injury  if  possible,  whereas  pressure  is  made 
more  centrally,  preferably  against  the  ramus  of  the  pubis.  The  artery 
may  be  compressed  for  wounds  of  the  veins  if  one  does  not  prefer  to 
ligate  the  artery  also,  a  procedure  that  has  been  carried  out  repeatedly 
to  arrest  venous  hemorrhage.  (Gensoul,  v.  Langenbeck.)  The  ligation 
should  always  be  double,  namely,  above  and  below  the  wound,  ar.d 
(532) 


1SJURIES  OF  THE  MUSCLES  OF  THE  THIGH.  533 

the  injured  portion  excised,  all  lateral  branches  being  carefully  ligated 
before  its  removal.  Marked  dilatation  of  the  smaller  arteries  after 
ligation  of  the  femoral  artery  may  cause  secondary  hemorrhage.  To 
obviate  this  some  surgeons  prefer  to  ligate  the  external  iliac.  Porter 
recommends  exposing  and  Ligating  the  artery  through  a  transverse 
incision  along  l'oupart's  ligament.  Suture  of  the  artery  (arteriorrhaphy) 
according  to  Jassikoffsky,  and  as  performed  by  Zoege  v.  Manteuffel  on 
the  femoral,  should  be  tried  in  appropriate  eases.  Kiimmell  proposes 
circular  suture  in  proper  cases. 

Suture  of  the  vein  is  preferable  if  the  wound  is  slight  and  severe 
hemorrhage  and  weak  heart  action  jeopardize  the  development  of  the 
collateral  circulation.  (Jordan.)  If  secondary  hemorrhage  follows 
lateral  suture,  double  ligation  is  indicated.  The  fear  of  air  entering  the 
vein  and  causing  pulmonary  embolism  is  unfounded;  this  only  occurs 
in  wounds  close  to  the  heart.  Death  from  this  cause  in  wounds  of  the 
femoral  vein  or  after  suture  is  not  known. 

As  to  gangrene  following  ligation:  the  circulation  is  rapidly  estab- 
lished through  the  collaterals  after  ligation  of  the  femoral  artery  above 
or  below  the  profunda,  especially  through  the  eirculus  obturatorius.  The 
conditions  are  less  favorable  if  ligation  of  the  femoral  vein  is  necessary 
as  the  position  and  condition  of  the  valves  of  the  collateral  veins  appar- 
ently hinders  the  free  return  of  blood  to  the  heart.  Formerly  the  limb 
was  amputated  at  the  hip-joint  for  fear  of  gangrene  (Stromeyer,  Pirogoff), 
Braune  particularly  having  shown  by  experiment  that  the  common 
femoral  vein  usually  transmits  all  the  blood  to  the  abdomen  It  was 
found,  however,  that  ligation  of  the  femoral  vein  in  extirpating  tumors 
was  not  followed  by  gangrene.  Eleven  cases  of  this  kind  have  been 
seen;  the  explanation  is  in  the  fact  that  the  pressure  of  the  tumor 
causes  the  gradual  establishment  of  the  collateral  circulation.  The 
later  observations  and  experiments  of  Braune  and  v.  Bergmann,  Kam- 
merer,  Niebergall,  Trczebicky,  Karpinsky,  and  Rotgans  have  proved  that 
the  femoral  vein  can  be  ligated  without  producing  gangrene  even  in  the 
absence  of  any  tumor. 

If  possible,  the  operation  of  ligating  the  femoral  vein  should  be  blood- 
less by  applying  the  Esmarch.  The  wound  should  be  packed  and  the 
limb  suspended  vertically  to  aid  the  venous  flow  and  overcome  the 
resistance  of  the  valves,  especially  those  of  the  circumflex  iliac  and 
obturator  veins.  Simultaneous  ligation  of  the  femoral  artery  and  vein 
was  followed  in  12  of  Kammerer's  22  cases  by  gangrene,  and  in  14  of 
Niebergall's  24  cases.  Kageyama's  statistics  give  gangrene  in  39  per 
cent,  of  the  cases  of  simultaneous  ligation  of  the  artery  and  vein  in  the 
extirpation  of  tumors  and  in  36  per  cent,  after  ligation  for  trauma. 


INJURIES  OF  THE  MUSCLES  OF  THE  THIGH. 

Rupture  of  the  Muscles. — Riders  not  infrequently  suffer  larger  or 
smaller  tears  of  the  adductors.    Maydl  reports  7  instances  of  laceration 


534  INJURIES  OF  THE  THIGH. 

of  the  iliopsoas  in  which  the  tear  was  produced  by  overexertion,  lifting 
heavy  bodies,  parturition,  tetanus,  or  the  attempt  to  prevent  a  fall 
backward.  Two  cases  seen  by  Thiem  were  apparently  associated  with 
fracture  of  the  transverse  processes  of  the  lumbar  vertebrae.  Maydl 
reports  several  cases  of  rupture  of  the  biceps,  one  simultaneous  with 
rupture  of  the  semimembranosus  and  semitendinosus.  The  ruptures  of 
the  quadriceps  are  most  interesting  and  important;  they  usually  result 
from  the  effort  to  maintain  an  erect  position  in  slipping  or  in  mountain- 
climbing,  the  contracted  muscle  being  stretched  passively  and  torn  by 
the  sudden  backward  movement  of  the  body.     (Konig.) 

If  the  tear  is  situated  in  the  rectus  at  the  middle  of  the  thigh,  a  depres- 
sion can  be  felt  and  above  it  the  swelling  of  the  retracted  muscle.  The 
patient  may  still  be  able  to  walk  as  a  large  part  of  the  extensor  apparatus 
is  still  intact.  The  full  use  of  the  limb  is  soon  recovered,  except  that 
mountain-climbing  is  difficult  on  account  of  the  weakening  of  the  pelvic 
connection  of  the  extensors.  If  the  rupture  lies  lower  in  the  combined 
tendon,  the  patella  remains  relaxed  during  extension  as  only  the  so-called 
reserve  extensors  attached  directly  to  the  leg  are  active.  At  first  the 
function  is  greatly  impaired;  later  the  lateral  muscles  may  become 
stronger  and  adequate. 

Treatment. — If  the  extended  limb  can  be  lifted  in  the  dorsal  position, 
massage  and  gymnastics  are  sufficient ;  if  elevation  is  impossible,  incision 
and  suture  are  preferable. 

Hernia  of  the  Muscles. — By  muscular  hernia  is  understood  in  general 
a  tumor-like  protrusion  of  a  portion  of  muscle  through  a  tear  in  the 
fascia  or  muscular  sheath.  Exceptionally  the  tear  in  the  fascia  is  pro- 
duced by  sharp  foreign  bodies  from  without  or  splinters  of  bone  in 
fracture;  the  protrusion  is  then  not  a  pure  hernia,  as  part  of  the  muscular 
fibres  are  usually  torn  with  the  fascia.  The  most  frequent  cause  is  the 
pressure  exercised  by  the  contracting  muscle  upon  the  fascia.  Farabeuf 
considers  this  pressure  too  slight  to  cause  a  tear.  Aside  from  the 
anatomical  inexactness  of  this  view,  one  need  only  be  reminded  of  the 
ability  of  many  athletes  to  break  iron  chains  by  contracting  the  biceps 
to  appreciate  the  pressure  exerted  by  the  contracting  muscle  upon  its 
sheath,  the  essential  being  that  the  muscle  contracts  more  quickly  than 
the  fascia  can  yield.  According  to  Bardeleben,  all  the  fascias  of  the  body 
are  attached  to  the  muscles  and  are  stretched  by  their  movements.  If 
the  latter  are  inco-ordinated,  the  danger  of  tearing  the  fascia  is  increased. 
Under  such  circumstances  it  is  not  necessary  to  assume  a  certain  brittle- 
ness  of  the  fascia  such  as  occurs  in  the  aged. 

The  favorite  seat  of  hernia  is  the  region  of  the  adductors;  Paradies 
found  15  cases,  chiefly  in  cavalrymen,  in  the  accessible  literature.  The 
effort  of  an  untrained  rider  to  keep  his  saddle  causes  sudden  violent 
contractions  of  the  adductors,  thus  tearing  their  sheath,  which  is  one  of 
the  weakest  parts  of  the  fascia  lata.  In  a  case  of  Dupont's  a  bilateral 
hernia  of  the  adductors  followed  sudden  adduction  of  the  legs  in  an 
effort  to  hold  a  heavy  body  between  them. 

Radwitz  reports  a  hernia  of  the  semimembranosus,  and  Hartmann 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR.  535 

a  hernia  at  the  front  outer  side  of  the  thigh  after  recovery  of  a  compound 
fracture  of  the  femur.  Hernia  of  the  biceps  is  also  reported.  The 
patients  were  all  males,  eighteen  to  forty  years  old.  The  tear  in  the 
fascia  can  rarely  be  felt,  and  there  are  apparently  cases  in  which  the 
prolapse  is  due  to  a  local  dilatation  of  the  aponeurosis.  Choux  reports 
a  radical  operation  of  a  hernia  in  which  the  aponeurosis  was  found  intact. 
Guinard  says  that  there  are  cases  of  apparent  hernia  which  take  place 
in  thin  uninjured  spots  of  the  muscle-sheath.  According  to  this,  the 
idea  of  muscular  prolapse  would  include  a  localized  stretching  of  the 
fascia  as  well  as  rupture. 

Treatment. — Compressing  or  elastic  bandages  never  produce  recovery. 
(Hess  was  the  first  to  attempt  a  radical  operation.  Once  recurrence 
followed  removal  of  the  prolapsed  portion  of  muscle  and  simple  suture 
of  the  skin,  so  in  a  later  case  he  also  sutured  the  freshened  fascia  and 
with  success.  Similarly,  Sellerbeck,  after  excising  the  prolapsed  portion 
of  muscle,  made  three  rows  of  buried  sutures  between  the  edges  of  the 
fascia  and  the  muscle.  The  patient  got  up  against  orders  on  the  seventh 
day,  and  recurrence  followed.  Choux  did  not  remove  the  muscle,  but 
made  a  purse-string  suture  about  it  with  silkworm-gut  after  excising  the 
dilated  portion  of  fascia.  Recovery  was  permanent  after  immobilizing 
for  twenty  days.  As  muscular  hernia  rarely  gives  marked  subjective 
or  functional  disturbance,  operation  by  the  above  methods  will  seldom 
be  necessary.  The  discomfort  at  the  outset  soon  disappears,  a  circum- 
stance worthy  of  note,  with  reference  to  accident  and  policy  claims. 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR. 

Fracture  of  the  shaft  is  most  common  in  workingmen,  twenty  to  sixty 
years  old,  and  in  children,  usually  affects  the  middle  third  of  the  femur, 
less  frequently  the  upper,  and  rarely  the  lower  third.  The  cause  may 
be  direct  or  indirect  violence  or  muscular  traction.  Direct  violence 
must  be  severe  to  fracture  the  adult  femur,  and  affects  more  particularly 
the  lower  third,  as,  for  example,  the  weight  of  a  falling  body,  runover 
accidents,  gunshot  fracture,  Such  fractures  are  apt  to  be  accompanied 
by  considerable  laceration  of  the  soft  parts.  Indirectly  fracture  results 
from  falling  upon  the  feet,  and  is  then  a  bow  fracture,  the  femur  being 
bent  beyond  the  limit  of  its  elasticity  like  a  stick  held  firmly  at  its  upper 
end  and  pressed  against  the  ground.  Corresponding  to  its  physiological 
curve  the  femur  first  breaks  in  front  on  the  convexity,  and  is  then  pressed 
together  at  its  concavity  behind  if  the  fracture  occurs  in  the  middle  or 
lower  third.  If  in  the  upper  third  close  to  the  great  trochanter,  one 
finds  a  tear  fracture  outward  and  forward  with  the  compression  .behind 
and  to  the  inner  side,  corresponding  to  the  curve  of  the  bone  prolonged 
from  Adams'  arch.     (Lossen.) 

Torsion  fractnre  is  also  produced  indirectly,  is  usually  situated  in  the 
upper  third,  and  is  dependent  partly  upon  muscular  action,  as,  for 
instance,  the  fracture  caused  by  a  misstep,  or  in  bowling  at  the  moment 


536 


INJURIES  OF  THE  THIGH. 


in  which  the  bowler  in  throwing  the  ball  supports  himself  upon  the 
limb  in  front  and  rotates  the  body  upon  it.  This  sudden  rotation  is 
the  chief  factor  in  producing  the  fracture.  It  is  also  produced  some- 
times by  a  sudden  movement  to  dodge  a  falling  body  or  in  rotating  the 
thigh  to  reduce  an  old  dislocation  of  the  hip. 

Infraction  is  very  rare.  It  occurs  occasionally  in  adults,  and  is  usually 
transverse  without  angular  deformity.  Fissures  are  very  seldom  seen 
in  the  shaft  as  independent  fractures.  Bouisson  saw  a  case  resulting 
from  an  oblique  blow  upon  the  hip  in  which  the  fissure,  over  6  inches 
long,  extended  from  the  middle  of  the  shaft  to  the  external  condyle. 

Complete  fracture  occurs  in  all  the  known  varieties.  Transverse 
fractures  are  confined  chiefly  to  the  epiphyseal  line  in  rhachitic  children 


Fig.  345. 


Fig.  346. 


Serrated  transverse  fracture  of  the  femur  in  a  child. 
iv.  Bruns.) 


Spiral  fracture  of  the  femur. 
(v.  Bruns.) 


or  adults.  Occasionally  they  are  subperiosteal  or  the  periosteum  is 
partially  torn.  The  surfaces  are  usually  serrated.  (Fig.  345.)  The 
serrations  may  be  engaged  and  somewhat  impacted.  Lateral  dis- 
placement and  angular  deformity  are  usually  slight. 

Oblique  fractures  constitute  the  great  majority.  The  obliquity  may 
be  so  pronounced  that  the  fracture  surfaces  are  parallel  to  the  long  axis 
for  some  distance;  they  may  also  be  so  smooth  and  sharp  as  to  resemble 
the  mouth-piece  of  a  clarionet,  hence  the  term  "fracture  en  bee  de 
flute." 

Spiral  fractures  produced  by  torsion,  often  by  muscular  traction,  are 
characterized  by  the  obliquity  and  sharpness  of  the  fragments,  one  line 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR. 


537 


of  the  fracture  running  in  the  long  axis  of  the  hone,  the  other  in  a  spiral. 
Fig.  346.)  It  is  most  common  in  the  upper  end  of  the  femur.  Fissures 
are  apt  to  radiate  from  both  fracture-lines  and  extend  to  the  adjacent 
joint.  The  sharp  fragments  may  pierce  the  soft  parts.  Corresponding 
to  the  normal  curve  of  the  femur,  the  spiral  usually  runs  from  the  lower 
inner  side  over  the  posterior  surface  upward  to  the  outer  surface.    (Stetter, 

Mermillod.) 

Multiple   and    splinter   fractures    have    nothing   characteristic.     The 
former  are  usually  at  the  upper  end  with  one  fragment  displaced,  the 

Fig.  347. 


Spiral  fracture  of  the  femur  with  a  typical  i 


il  splinter. 


Bruns.) 


shaft  being  divided  into  three  large  fragments.  The  middle  fragment 
does  not  always  include  the  entire  thickness  of  the  shaft  uniformly,  but 
is  more  often  a  wedge-shaped  or  rhomboid  piece  from  the  anterior  sur- 
face.    (Fig.  347.) 

In  spite  of  the  diversity  of  form,  the  nature  and  direction  of  fracture 
of  the  femur  follow  certain  laws  according  as  the  break  is  in  the  upper, 
middle,  or  lower  third  of  the  shaft.  In  the  upper  third  the  fracture  is 
almost  alwavs  oblique,  the  line  running  from  above  and  without  down- 


538  INJURIES  OF  THE  THIGH. 

ward  and  inward.  In  the  middle  third  the  oblique  fracture  also  pre- 
dominates, but  the  line  runs  in  the  large  majority  of  cases  from  above 
and  behind  downward  and  forward,  either  at  an  acute  angle,  at  an 
angle  of  45  degrees,  or  almost  in  the  long  axis  of  the  femur.  In  the 
lower  third,  where  the  spongiosa  begins  and  the  corticalis  becomes 
thinner,  one  meets  with  transversa  but  more  often  oblique  fractures,  a 
characteristic  of  the  latter  being  that  they  are  commonly  oblique  from 
above  and  behind  downward  and  forward. 

In  all  these  oblique  fractures  there  is  a  tendency  to  overriding,  and  if 
the  periosteum  is  torn,  which  is  common,  there  is  a  somewhat  typical  dis- 
placement depending  in  turn  upon  the  direction  of  the  violence.  The 
latter  is,  as  a  rule,  applied  from  the  outer  side,  and  thus  forces  the  lower 
end  of  the  femur  inward.  Other  factors  are  the  curve  of  the  bone  and 
the  traction  of  the  muscles  on  the  fragments.  Rotation  of  the  lower 
fragment  about  the  long  axis  is  common  to  all  fractures  of  the  femur, 
and  is  due  to  the  weight  of  the  limb. 

In  fractures  of  the  upper  third  the  upper  fragment  is  abducted  and 
slightly  flexed  by  the  iliopsoas  and  the  glutei.  The  lower  fragment  is 
displaced  inward  and  upward  by  the  violence  and  by  the  adductors. 
The  fragments  thus  override  and  cross,  and  the  limb  is  shortened. 
There  is  thus  an  angular  deformity  outward  and  forward  at  the  point 
of  fracture,  distinct  in  thin  subjects,  in  muscular  or  fat  subjects  occa- 
sionally concealed  by  flexion  of  the  neck.  (Roser.)  The  upper  frag- 
ment may  be  splintered.  (Bennet.)  Displacement  may  be  absent  if  the 
fracture  is  close  to  the  trochanter,  subtrochanteric  fracture,  even  if  the 
break  is  oblique.  Nicoladoni  refers  this  absence  of  displacement  to 
the  dense  fibrous  tissue  forming  the  attachment  of  the  muscles  on  the 
bone  at  this  point. 

In  fractures  of  the  middle  third  the  upper  fragment  is  displaced  for- 
ward and  outward  if  the  line  approaches  the  upper  third.  If  below 
the  insertion  of  the  adductors,  the  upper  fragment  is  drawn  forward 
and  inward,  the  lower  fragment  outward,  backward,  and  upward. 

In  the  lower  third  the  upper  fragment  is  drawn  forward  and  inward 
by  the  adductors,  occasionally  so  far  forward  that  it  penetrates  the 
muscles  and  the  bursa  extensorum  and  lies  beneath  the  skin  or  pierces 
it.  The  lower  fragment  is  drawn  upward  and  backward  by  the  elastic 
retraction  of  the  muscles.  The  occasional  flexion  of  the  lower  frag- 
ment at  the  knee-joint,  so  that  the  fracture  surface  approaches  the 
popliteal  space,  was  referred  by  Boyer  to  the  action  of  the  gastrocnemii, 
by  Lauenstein  to  a  fall  after  the  fracture. 

Symptoms. — If  the  fracture  is  incomplete  or  the  periosteum  partially 
intact,  there  are  merely  pain,  swelling,  and  functional  impairment.  In  the 
dorsal  position,  if  the  patient  attempts  to  lift  the  limb  angular  deformity 
is  noticeable  at  the  point  of  fracture.  False  motion  and  crepitus  are 
obtainable  by  shifting  the  fragments  upon  each  other.  If  the  periosteum 
is  completely  torn,  the  displacement  and  deformity  are  recognizable  on 
comparing  with  the  other  limb.  The  foot  and  patella  are  always  rotated 
outward.     Shortening  may  be  slight  or  even  C  inches  if  the  fragments 


FRACTURE  OF  Till:  SHAFT  OF  THE  FEMUR.  539 

override.  The  above  symptoms  are  usually  so  pronounced  that  the  diag- 
nosis can  be  made  at  a  glance.  If  the  site  of  fracture  cannot  be  deter- 
mined, as  in  muscular  patients,  the  examination  can  be  made  under 
anaesthesia  and  with  the  .r-ray.  The  latter  gives  the  best  information; 
two  views  should  always  be  taken,  anterior  or  posterior  and  lateral,  to 
avoid  deception. 

Prognosis. — The  prognosis  is  generally  favorable;  even  compound 
fractures,  formerly  so  much  dreaded,  heal  at  the  present  time  under 
aseptic  measures.  Bony  union  occurs  in  children  in  about  four  weeks, 
in  adults  in  from  six  to  eight  weeks.  Extension  treatment  promotes 
the  rapid  formation  of  callus,  does  not  hinder  the  circulation,  and  over- 
comes the  shortening  most  effectually.  Formerly  one  was  satisfied  if  a 
shortening  of  |  to  \\  inches  persisted  in  the  usual  oblique  fractures. 
v.  Volkmann  cites  110  cases  treated  by  extension,  of  which  87  healed 
without  shortening;  in  the  other  cases  it  was  only  T^  to  f  inch.  Fractures 
in  the  upper  third  unite  in  forty  days  with  an  average  shortening  of  •§■ 
inch,  in  the  middle  third  in  thirty-two  days  with  -^  inch  shortening,  and 
in  the  lower  third  in  thirty-four  days  with  \  inch  shortening.   (Hertzberg.) 

Pseudarthrosis  is  not  very  rare,  and  is  usually  attributed  to  marked 
overriding  or  interposition  of  muscles.  In  elderly  individuals  the  possi- 
bility of  hypostatic  pneumonia  and  decubitus  are  to  be  borne  in  mind, 
and  in  very  stout  people  the  fatal  fat-embolus.  Serous  or  sanguineous 
effusion  in  the  knee-joint  is  rather  common  in  fracture  of  the  lower 
or  middle  third,  and  is  due  either  to  the  violence  or  to  fissures  extending 
into  the  joint.  The  effusions  occurring  later  during  the  first  attempts 
to  walk  are  due  to  the  fact  that  motion  acts  like  a  sprain  upon  the 
dry  and  rigid  joint,  (v.  Volkmann.)  Effusions  of  the  latter  sort  often 
persist  for  some  time;  the  former  variety  are  usually  absorbed  during 
recovery. 

The  later  usefulness  of  the  limb  depends  upon  the  treatment.  The 
accident  statistics  of  Haenel  are  interesting.  Of  121  fractures  of  the 
femur,  only  39  recovered  fully,  in  75  the  injury  was  permanent  with  an 
average  loss  in  earning-efficiency  of  28  per  cent.  The  average  period  of 
complete  recovery  was  thirteen  and  one-half  months.  The  results  were 
bad  in  direct  relation  to  age.  The  most  frequent  causes  of  functional 
impairment  were  shortening  and  stiffness  of  the  knee-joint.  Muscular 
atrophy,  exuberant  callus,  pain,  pseudarthrosis,  and  decubitus  also 
played  an  important  part. 

Treatment. — While  the  pelvis  and  when  possible  the  upper  part  of 
the  femur  are  steadied  by  an  assistant,  reposition  is  effected  by  grasping 
the  foot  with  both  hands,  lifting  the  limb  carefully  and  fully,  and  rotat- 
ing steadily  with  increasing  traction  until  the  long  axis  of  the  metacarpal 
of  the  great  toe,  the  inner  border  of  the  patella,  and  the  anterior-superior 
spine  are  in  a  straight  line.  If  the  fracture  lies  in  the  upper  or  middle 
third,  the  limb  should  be  abducted  till  the  fragments  are  apposed. 
Impalement  of  the  soft  parts  is  sometimes  recognizable  by  a  pitting  of 
the  skin  at  the  corresponding  spot.  In  such  cases  interposition  takes 
place  easily,  and  the  impalement  should  be  freed  either  by  rotating  or 


540 


INJURIES  OF  THE  THIGH. 


through  a  small  incision.  Reduction  is  most  easily  effected  upon  a 
Schede  table  or  with  v.  Bruns'  apparatus. 

The  various  immobilization  splints  and  apparatus  formerly  used 
often  did  more  harm  than  good,  and  are  replaced  at  the  present  time  by 
position-,  strip-,  and  plaster-splints  and  continuous  weight-extension. 
Temporarily  the  patient  may  be  placed  in  the  so-called  Pott's  lateral 
position,  namely,  upon  the  injured  sick-  with  the  knee  and  hip  flexed 
and  the  limb  steadied  between  sand-bags.  This  is  especially  useful  in 
those  instances  in  which  the  upper  fragment  is  flexed,  but  is  uncom- 
fortable if  prolonged.  In  the  dorsal  position  a  double  inclined  plane 
may  be  used  similar  to  that  of  v.  Esmarch. 

For  transportation,  especially  of  delirious  patients,  one  of  the  various 
strip  splints  is  necessary,  either  Bonnet's  woven-wire  splint  or  a  strong 
outer  splint,  the  width  of  the  hand,  extending  from  the  pelvis  to  the 
foot.     It  should  be  well  padded  at  the  pelvis,  knee,  and  foot,  and  have 


Fig.  348. 


Helferich's  extension   splint. 

a  cross-piece  at  the  foot  to  prevent  rotation.  A  thick  pad  should  be 
laid  against  the  outwardly  displaced  fragment.  To  this  v.  Esmarch 
added  extension  by  means  of  adhesive-plaster  strips,  a  spreader,  an  iron 
hook  and  elastic  band  at  the  foot,  and  counterextension  by  means  of 
a  perineal  band.  Smith's  anterior  wire  splint,  made  in  an  emergency, 
of  telegraph  wire,  and  as  used  to  advantage  for  shot-fractures  in  recent 
wTars,  is  also  serviceable.  Roser  suggests  a  gutter  splint  of  three  pieces 
that  can  be  drawn  out  to  any  desired  length. 

A  plaster-splint  should  include  the  foot  of  the  affected  limb,  the  pelvis, 
and  the  upper  half  of  the  sound  thigh.  Its  disadvantage  is  the  subse- 
quent loosening  due  to  atrophy  or  diminution  of  the  swelling.  Even 
if  accurately  applied  immediately  after  injury,  slight  lateral  deviation 
and  thereby  increased  shortening  are  unavoidable.  It  should  never  be 
applied  if  the  soft  parts  are  greatly  swollen,  as  gangrene  of  the  entire 
extremity  may  result.     In  applying  the  splint  the  patient  should  be 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR. 


541 


placed  upon  the  pelvic  support  (v.  Volkmann,   Bardeleben,  v.  Brims, 
Schede),  the  fracture  bandaged  first,  and  then  the  adjacent  joints. 

Continuous  weight-extension  as  employed  for  fracture  of  the  neck  is 
by  far  the  best  method.  A  pillow  should  be  placed  under  the  knee  to 
prevent  hyperextension  and  pain.  The  marked  abduction  and  flexion 
of  the  upper  fragment  in  fractures  of  the  upper  and  middle  third  are 
overcome  by  abducting  the  limb  upon  an  inclined  plane.  Lateral 
traction  may  be  necessary  to  overcome  pronounced  inflexion.  Ilel- 
ferich's  method  is  shown  in  Fig.  348.  It  is  important  to  inspect  the 
limb  constantly  to  prevent  decubitus  and  to  maintain  the  proper  position. 
It  is  also  important  to  measure  the  length  of  the  limb  from  time  to  time, 
comparing  it  with  the  sound  limb.     (See  Fracture  of  Neck.) 

Fig.  349. 


Schede's  method  of  vertical  suspension. 

Extension  is  counterindicated  for  fractures  close  to  the  knee-joint  as 
the  ligaments  are  easily  overstretched,  v.  Volkmann's  T-splint,  or,  better, 
v.  Bruns'  new  splint,  is  useful,  especially  for  transverse  fracture  without 
much  displacement.  If  displacement  exists,  extension  is  applied  for 
from  eight  to  twelve  days  and  then  replaced  by  a  plaster-splint.  Beely 
and  Treves  recommend  flexing  the  knee  and  suspending  the  limb  if  it  is 
desirable  to  overcome  the  displacement  at  the  outset.  This  is  impossible 
if  the  soft  parts  are  much  swollen  or  there  is  an  effusion  of  blood  in  the 


542 


IX JURIES  OF  THE  THIGH. 


Fig.  350. 


knee-joint;  Bryant  therefore  proposes  tenotomy  of  the  Achilles  tendon 
to  relax  the  gastrocnemii,  the  cause  of  the  displacement.  Treves  did 
this  in  3  cases,  later  using  weight-extension.  Suspension  and  extension 
may  be  combined  satisfactorily  by  using  Beely's  plaster-  and  hemp  strip- 
splint.     If  the  patient  is  restless,  it  should  include  the  pelvis. 

In  young  children  immobilization  was  formerly  very  difficult  on 
account  of  the  character  of  the  soft  parts  of  the  thigh  and  the  fulness 
of  the  abdomen.  A  plaster-splint  or  even  three-piec?  strip  splint  with 
a  long  outer  strip  is  badly  borne,  as  the  skin  is  always  soiled  beneath 
and  eczema  and  excoriation  produced;  Schede's  vertical  suspension 
obviates  this.  (Fig.  349.)  A  weight  of  4  to  8  pounds  is  sufficient. 
The  method  gives  great  comfort;  the  child  can  be   kept   clean,  and 

union  is  rapid,  usually  complete  in 
about  three  weeks.  It  is  not  necessary, 
as  recommended  by  Lentze,  to  enclose 
the  foot  and  leg  in  plaster.  In  fact, 
this  is  apt  to  produce  necrosis  of  the  skin. 
For  fracture  of  the  neck  acquired  during 
delivery  the  thigh  may  be  flexed  upon 
the  abdomen  and  held  by  adhesive  strips 
encircling  the  body.  This  allows  the 
child  to  be  bathed  and  cleaned. 

After  union  has  taken  place  and  ex- 
tension is  removed,  as  the  callus  is  still 
soft  and  may  bend  or  break,  a  remov- 
able silicate-splint  should  be  applied  and 
the  limb  strengthened  by  methodical 
massage  and  gymnastics. 

The  ambulant  treatment,  which  has 
recently  won  many  advocates,  should  be 
mentioned,  although  the  extension  splint 
is  unquestionably  most  worthy  of  re- 
commendation for  the  practising  sur- 
geon. Hessing  was  the  first  to  employ 
the  ambulant  treatment  successfully  for 
recent  fractures  of  the  leg  and  thigh. 
He  first  put  on  a  glue  dressing,  and  over 
this  applied  a  sheath  splint  apparatus 
constructed  over  a  wooden  model,  and 
which  exercised  continuous  traction  and 
held  the  fragments  in  position.  (Fig. 
350.)  On  the  same  principle  splints 
have  been  made  and  recommended  by 
Dombrowski,  Reyher,  Selenkow,  Thomas,  Harbordt,  Heusner,  Lier- 
mann,  and  v.  Bruns,  but  they  are  not  so  complete  as  Hessing's, 
although  doubtless  of  value  in  the  hands  of  competent  surgeons. 

v.  Bruns'  combination  ambulant  and  bed-splint  (Figs.  351  to  354)  is 
the  most  serviceable  for  general  use.     It  consists  of  two  side  rods,  a 


Hessing's  ambulant  splint. 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR. 


543 


perineal  ring,  and  a  foot-brace.  WheD  recumbent,  the  limb  rests  upon 
several  broad  linen  strips  stretched  between  the  rods,  which  latter  are 
adjustable.  ( )ver  the  front  are  fastened  several  narrow  straps.  Taking, 
for  example,  a  fracture  of  the  middle  third,  the  splint  is  first  used  as 
an  immobilization  splint  with  traction  for  two  or  three  weeks.  Strips 
of  adhesive  plaster  are  fastened  on  both  sides  of  the  limb  and  attached 
to  a  spreader,  to  which  a  cord  and  weight  are  fastened.  (Figs.  351, 
352.)  The  extension  is  removed  in  about  three  weeks,  a  light  plaster- 
of- Paris-splint  applied  from  the  toes  to  the  groin,  and  the  frame  adjusted 
over  it  as  an  ambulant  splint,  the  foot-board  being  removed  and  the 

Tig.  351. 


v.  Bruns'  combination  bed  and  ambulant  splint. 

brace  so  applied  under  the  foot  that  the  adhesive  straps  can  be  drawn 
down  and  tied  to  it  to  exert  traction,  countertraction  being  effected  by 
the  perineal  ring  against  the  tuber  ischii.  (Figs.  353  and  354.)  Trac- 
tion is  only  necessary  for  oblique  fracture ;  in  simple  transverse  fracture 
the  splint  may  be  made  portable  from  the  first. 

Korsch,  Albers,  and  Dollinger  have  recently  attempted  to  simplify  the 
ambulant  treatment  still  further  by  using  a  plaster-splint  alone.  Korsch 
applied  it,  as  in  fractures  of  the  leg,  directly  over  the  shaven  skin  with- 
out any  padding,  the  splint,  extending  from  the  midtarsus  to  the  hip, 
exerting  pressure  against  the  malleoli,  dorsum  of  the  foot,  and  heel,  and 


544 


INJURIES  OF  THE  THIGH. 


above  against  the  tuber  ischii  by  means  of  a  perineal  pad  made  of  wire 
and  sheet  iron.  Albers'  method  was  similar.  Dollinger's  method  is 
very  useful:  The  splint  is  put  on  in  two  parts;  a  thick  cotton  pad  is  laid 
against  the  sole  of  the  foot  and  the  plaster-splint  moulded  over  the 
foot,  leg,  and  lower  third  of  the  thigh,  fitting  closely  about  the  ankle 
and  the  condyles  of  the  femur.  The  patient  is  then  carefully  placed 
in  a  Sayre  frame  with  a  block  1  to  H  inches  thick  under  the  sound  foot. 
The  foot  part  of  the  plaster-splint  is  fastened  to  a  hook  screwed  in  the 


Fig.  353. 


Fig.  354. 


v.  Bruns'  splint  when  ambulant. 


floor.  A  pad  of  plaster-of-Paris  is  incorporated  in  a  long  linen  strip 
and  placed  under  the  tuber  ischii,  the  ends  of  the  strip  being  tied  together 
above  the  brim  of  the  pelvis  and  caught  in  the  hook  of  the  suspension 
pulley.  The  limb  is  then  lengthened  appropriately  by  raising  the  patient. 
The  pelvis  and  thigh  are  then  encased  in  plaster  blending  firmly  with 
the  lower  splint.  With  a  high  sole  on  the  sound  foot  the  patient  goes 
about  with  crutches  or  a  cane.  Dollinger's  results  are  very  good.  Also 
those  obtained  by  Graff  upon  Schede's  material.     According  to  Graff, 


FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR. 


545 


energetic  extension  is  of  first  importance,  and  Sehede's  table  is  well 
adapted  to  this  end.  He  advises  immediate  application  of  the  portable 
splint  only  where  the  swelling  and  displacement  are  slight. 


Fig.  355. 


Buck's  extension  with  a  Yolkmann  sliding  rest.      (Stimson.  i 

Fig.  356. 


Hodgen's  suspension  splint.     (Stimson.) 


Vol.  III.— 35 


546  INJURIES  OF  THE  THIGH. 

[The  methods  most  widely  used  in  America  are  Buck's  extension  and 
Hodgen's  suspension,  which  hardly  need  further  description  here  than 
that  given  in  the  accompanying  figures.] 

The  author  recommends  the  ambulant  treatment  only  to  very  expe- 
rienced surgeons.  In  less  skilful  hands  it  may  do  great  harm;  angular 
union  is  unfortunately  not  a  rarity  if  the  extension  or  plaster-splint  is 
improperly  applied.  If  a  fracture  with  angular  union  is  still  pliable, 
it  may  be  refractured ;  otherwise  oblique  osteotomy  and  forcible  extension 
have  been  shown  by  experience  to  be  most  practical. 

To  cure  a  pseudarthrosis  of  the  femur,  all  the  available  measures 
extant  have  been  used.  The  author  has  repeatedly  effected  a  cure  by 
allowing  the  patients  to  go  about  in  a  well-fitting  sheath  splint,  the 
constant  irritation  stimulating  the  necessary  formation  of  callus.  If 
union  is  prevented  by  interposition  of  muscle,  the  fracture-ends  should 
be  exposed  subperiosteal^7 ,  freshened,  and  fixed  either  with  ivory  pegs, 
steel  screws,  silver  wire,  by  Sick's  method  of  screwing  on  ivory  plates, 
by  ParkhilFs  silver-plated  screws  and  plates,  or  by  rabbeting  and  nailing 
the  fragments  as  done  by  v.  Volkmann.  To  stimulate  bony  union  the 
patient  should  go  about  in  a  supporting  apparatus  as  soon  as  possible. 


GUNSHOT-WOUNDS  OF  THE  THIGH. 

The  introduction  of  small-calibre  firearms  and  antisepsis  have  so 
changed  the  conditions  of  gunshot-wounds  of  the  thigh  that  the  expe- 
rience of  previous  wars  no  longer  applies,  so  that  in  the  following  only 
the  observations  made  by  Kiittner  in  the  South  African  War  will  be 
considered. 

Gunshot-wounds  of  the  thigh  are  very  common,  perhaps  slightly  less 
so  than  formerly,  possibly  due  to  the  fact  that  modern  warfare  is  more 
protracted  and  carried  on  less  in  the  open  on  account  of  smokeless 
powder  and  the  greater  range  of  modern  weapons.  Wounds  of  the  soft 
parts  are  especially  frequent  as  the  muscles  of  the  thigh  are  very  thick 
and  the  small-calibre  bullet  reaches  the  bone  less  easily  than  the  larger 
projectiles.  Wounds  of  the  soft  parts  show  a  distinct  tendency  to 
primary  union  on  account  of  the  smallness  of  the  opening  and  of  the 
track.  Very  long  tracks  are  sometimes  found,  the  wound  of  entrance 
at  the  knee,  the  wound  of  exit  in  the  hip;  the  bullet  not  infrequently 
lodges.  Large  wounds  of  exit  are  produced  only  by  shots  at  short  range 
from  the  action  of  the  powder  gas ;  they  are  very  similar  to  the  wounds 
of  exit  made  by  the  partially  coated  (lead  tip  or  Dum-Dum)  bullets, 
large  areas  of  skin  and  muscle  being  extensively  lacerated  and  shat- 
tered. 

In  recent  wars  schrapnel  wounds  were  numerous,  the  bullet  frequently 
carrying  pieces  of  cloth  with  it  and  lodging  and  producing  infection. 
The  wounds  made  by  heavy  ordnance  and  secondary  projectiles  are 
very  diverse.  After  the  battle  of  Magersfontein  severe  wounds  of  the 
soft  parts  were  seen  which  were  produced  by  pieces  of  rock  hurled 


GUNSHOT  WO  USDS  OF  THE  THIGH.  547 

about  by  the  projectiles,  also  extensive  burns  made  by  metal  fragments 
ami  kernels  of  powder  from  bursting  shells. 

Wounds  of  the  vessels  and  nerves  are  more  often  slight  on  account 
of  the  flat  trajectory  and  the  small  calibre  of  the  bullet.  Wounds  of  the 
femoral  artery  more  frequently  cause  aneurism  than  formerly,  as  the 
blood  finds  its  way  out  less  easily  through  the  narrow  track.  The  sciatic 
was  often  involved,  usually  only  partly  torn,  occasionally  split,  and 
repeatedly  followed  by  neuritis. 

Gunshot-fractures  of  the  femur  are  perhaps  the  most  important  of 
all  gunshot-wounds  on  account  of  their  frequency  and  the  difficulty  of 
their  treatment.  The  shaft  is  more  often  affected  than  the  epiphysis. 
In  the  Franco-Prussian  War  the  shaft  was  affected  in  its  upper  third 
in  29  per  cent.,  in  the  middle  third  in  20  per  cent.,  in  the  lower  third 
in  26  per  cent.,  and  in  an  indefinite  situation  in  25  per  cent,  of  the  cases. 
Knowledge  of  and  interest  in  fractures  made  by  small-calibre  bullets 
have  been  greatly  increased  in  recent  wars  by  the  a>ray.  Kiittner  and 
Makins  have  published  a  series  of  pictures  ranging  from  simple  oblique 
fracture  to  very  extensive  splinter' ng. 

Splintering  (comminution)  is  the  rule  in  fractures  of  the  shaft  made 
by  metal-coated  bullets,  the  zone  at  all  ranges  being  the  same,  4|  to 
5j  inches.  At  close  range  the  splinters  are  usually  small,  at  long  range 
large ;  the  largest  observed  in  the  femur  was  h\  inches  long.  The  typical 
form  is  the  "butterfly-fracture"  with  extensive  shattering.  (See  p.  139.) 
The  bullet  not  infrequently  breaks  into  fragments  or  lodges  in  the  soft 
parts;  effusion  in  the  adjacent  joint  is  very  common.  The  wound  of 
exit  is  usually  small,  even  at  close  range,  not  being  more  than  1  to  1^ 
inches  deep  and  f  inch  wide.  Wounds  of  the  epiphysis  are  less  serious 
than  those  of  the  shaft.  Round-hole  perforation  without  splintering  has 
been  seen  at  either  end  of  the  femur;  round-hole  wounds  of  the  tro- 
chanter may  behave  almost  like  an  ordinary  wound  of  the  soft  parts. 
Extensive  comminution  of  the  epiphysis  occurs  only  at  short  range, 
and  is  especially  dangerous  on  account  of  the  proximity  of  the  joint. 

Prognosis. — The  prognosis  of  gunshot  fractures  of  the  thigh  depends 
upon  the  extent  of  involvement  of  the  soft  parts  more  than  upon  the 
damage  to  the  bone;  also  upon  the  treatment  and  external  conditions. 
In  respect  to  the  latter,  transportation  is  significant,  early  and  long 
transportation  decreasing  the  chances  of  aseptic  recovery.  Under  the 
proper  circumstances  and  care  the  severest  splintering  may  heal  if  the 
skin-wound  is  small  and  no  infection  occurs.  Delayed  union  and 
refracture  are  possible  and  pseudarthrosis  is  not  very  uncommon. 

Treatment. — The  treatment  should  be  as  conservative  as  possible. 
Primary  amputation  will  be  considered  only  for  extensive  shattering  as 
produced  by  close-range  shots,  bomb-shell  fragments,  partially  coated 
bullets,  and  secondary  projectiles.  Fractures  produced  by  metal-coated 
bullets  require  simple  occlusion  of  the  wounds  and  careful  immobiliza- 
tion on  the  battlefield.  A  plaster-splint  that  includes  the  pelvis  is  best, 
although  a  long  outer  splint  may  be  used  in  an  emergency.  Under 
auspicious  circumstances  the  plaster-splint  may  be  left  on  till  union  is 


548  IS  JURIES  OF  THE  THIGH. 

complete;  if  the  patient  is  transferred  early  to  a  hospital,  extension 
should  be  applied.  Suppuration  demands  free  exposure  and  cleansing 
of  the  fracture  area,  removal  of  loose  fragments  and  foreign  bodies, 
counteropening,  and  drainage.  Secondary  hemorrhage  is  dangerous  and 
usually  requires  amputation.  Amputation  should  also  be  done  promptly 
if  general  infection  is  imminent. 


CHAPTEK    X  X  VIII. 

DISEASES  OF  THE  THIGH. 
DISEASES  OF  THE  SOFT  PARTS  OF  THE  THIGH. 

Aneurism. — Aneurism  of  the  femoral  artery  is  four  times  less  frequent 
than  that  of  the  popliteal;  Delbet  has  collected  35  eases.  Trauma  is 
the  usual  cause,  although  it  is  certain  that  diseases  of  the  arterial  wall, 
particularly  endarteritis  or  congenital  weakness  of  the  tunica  media, 
often  act  as  predisposing  causes.  Not  infrequently  multiple  aneurisms 
are  met  with  along  the  artery;  Lowe,  Scarpa,  and  Monro  report  cases 
of  three  or  four  along  the  femoral  artery.  In  Scarpa's  triangle  the 
aneurism  is  usually  round,  but  farther  down  it  is  more  spindle-shaped. 
The  femoral  vein  is  seldom  compressed.  (Edema  of  the  limb  is  less 
common  than  in  popliteal  aneurism.  Occasionally  pain,  twitching  of 
the  muscles,  and  formication  develop.  As  in  all  other  aneurisms,  the 
dilatation  is  gradual;  spontaneous  recovery  happens  occasionally. 

If  the  aneurism  is  in  a  lateral  branch,  as  is  sometimes  the  case,  the 
diagnosis  mav  be  difficult  if  the  tumor  cannot  be  distinguished  from 
the  femoral  artery.  The  pulse,  however,  of  the  posterior  tibial  is 
unchanged  unless  the  main  trunk  is  affected.  Endogenous  aneurisms 
are  most  common  in  the  upper  third  of  the  thigh,  and  grow  larger  than 
in  the  lower  third,  where  the  sartorius  prevents  their  development  some- 
what. They  are  easily  confused  with  cold  abscesses  or  gra vitation 
abscesses. 

Treatment. — Compression  should  be  tried  first,  either  digital,  or  with 
an  elastic  bandage,  or  the  attempt  made  to  produce  clotting  by  means 
of  a  pad  and  bandage  when  the  position  of  the  aneurism  is  favorable. 
In  applying  an  elastic  bandage  the  limb  should  be  elevated  vertically  and 
bandaged  from  the  foot  upward;  the  second  bandage  is  then  applied 
over  the  aneurism,  the  first  removed,  and  the  former  left  on  for  about 
an  hour  and  a  half;  after  removing  it  digital  pressure  is  renewed  and 
continued  as  long  as  possible.  (Reid.)  Delbet  saw  fairly  good  results 
from  compression:  76  recoveries  in  111  cases;  in  5  the  aneurism  rup- 
tured. 

Ligation  or  extirpation  is  indicated  if  compression  fails.  Delbet 
cites  17  recoveries  in  30  cases  after  ligation;  in  2  cases  an  aneurism 
developed  later  at  the  point  of  ligation.  Gangrene  occurred  in  4,  in  3 
of  which  the  aneurism  was  diffuse.  Excision  gives  better  results  than 
ligation.  The  operation  is  often  difficult,  as  the  femoral  vein  especially 
has  to  be  protected  and  avoided  if  possible.  As  stated  previously  (see 
Injuries   of  Vessels  of  Thigh),   simultaneous   ligation   of  the   femoral 

(549) 


550  DISEASES  OF  THE  THIGH. 

artery  and  vein  is  not  necessarily  followed  by  gangrene.  The  teehnic 
of  excision  of  an  aneurism  is  practically  the  same  as  the  operation  for 
injuries  of  the  arteries. 

Arteriovenous  aneurism  is  not  infrequently  met  with  in  the  thigh,  and 
usually  develops  from  wounds  produced  by  sharp  instruments  or  pro- 
jectiles. Such  have  been  recently  described  by  Konig  and  Thiel;  one 
of  these  was  situated  in  the  middle  of  the  thigh,  and  was  removed  by 
v.  Bergmann  under  application  of  the  Esmarch  after  double  ligation  of 
the  femoral  artery  and  vein  above  and  below  the  tumor.  No  bad 
results  followed.  In  Thiel's  case  the  aneurism,  beneath  Poupart's 
ligament,  could  be  removed  only  after  double  ligation  and  division  of 
the  external  iliac  artery,  the  femoral  artery  and  vein  below  the  tumor, 
and  the  external  iliac  vein  and  profunda  artery  and  vein.  Recovery 
was  complete. 

Varicose  Veins  of  the  Thigh. — Varicosities  of  the  cutaneous  veins 
of  the  thigh  not  infrequently  develop  as  the  result  of  engorgement  of 
the  venous  circulation  of  the  thigh,  especially  in  multiparas  or  individuals 
whose  occupation  compels  them  to  stand,  walk,  or  ride  horseback  a 
great  deal.  The  bluish,  sacculated,  and  tortuous  appearance  of  the 
superficial  veins  is  well  known.  The  saphenous  vein  especially  shows 
marked  dilatation  from  the  falciform  process  to  the  knee.  (See  Plate 
XVIII.)  Rupture  sometimes  causes  fatal  hemorrhage.  Occasionally 
one  sees  periphlebitis,  suppuration,  thrombosis,  with  or  without  calcium 
deposits,  and  phleboliths. 

Treatment. — Compression  by  means  of  elastic  stockings  or  bandages 
should  first  be  tried.  If  unsuccessful,  excision  (Madelung,  Casati),  or, 
better,  Trendelenburg's  ligation  of  the  saphenous  vein  is  indicated.  The 
results  of  operation  are  very  satisfactory.  (Faisst.)  The  saphenous 
vein  is  exposed,  double  ligated,  divided,  and  the  intervening  piece  of 
vein  removed.  Recently  Wenzel  warmly  recommended  a  circular  inci- 
sion around  the  thigh. 

Lymphangiectasis. — Dilatation  of  the  lymphatics,  as,  for  example, 
after  total  extirpation  of  the  inguinal  glands,  may  lead  to  elephantiasis. 
If  of  long  duration,  there  may  be  hyperplasia  and  great  thickening  of 
the  skin  and  subcutaneous  tissue.  Rupture,  fistulas,  and  lymphorrhcea 
may  follow. 

Treatment. — The  treatment  is  the  same  as  that  of  varicose  veins,  but 
the  prognosis  is  less  favorable.  Thermopuncture  often  gives  the  best 
results.  In  elephantiasis  excision  of  ellipsoid-shaped  sections  of  skin 
and  ligation  of  the  femoral  are  also  recommended;  the  results  are  said 
to  be  favorable. 

Riders'  Bone. — An  osteoma  occasionally  forms  in  the  adductors  of 
riders.  Usually  the  cause  is  the  constant  irritation  of  the  saddle.  The 
process  is  most  frequently  an  inflammation  of  the  muscle  leading  to 
the  formation  of  bone.  It  may  be  due,  however,  to  injury  of  the  muscle 
at  its  origin  resulting  in  the  growth  of  the  periosteum  along  the  course 
of  the  adductors,  or  a  piece  of  bone  may  be  chipped  off  by  trauma  and 
continue  to  grow  in  the  muscle.     The  growth  has  also  been  found  in  the 


INFLA  MM  A  TOR  V  PROCESSES  IN  THE  FEMUR.  551 

pectineus,  vastus,  and  gracilis,     [f  the  muscle  is  relaxed,  the  formation 

can  be  felt  as  a   hard  mass,  varying  from    1    to  6  inches  long.      It   may 
develop  in  two  weeks.     Ludwig  reports  :!  eases  of  osteoma  in  the  vastus 

externus  of  the  left  thigh  of  cavalrymen.    They  were  due  to  the  Mows 
of  the  sword-hilt  upon  the  outer  side  of  the  thigh  during  1  ng  gallops 

Upon  horses  with  hard  hacks. 

Treatment. — Cases  are  reported  in  which  the  growth  diminished  or 
disappeared,  if  not  too  large,  under  massage  and  w  -t  compresses.  In 
others,  inunctions  of  iodine  ointment  or  ek'ctropuncture  were  successful. 
Excision  is  most  certain,  hut  may  he  difficult  as  the  growth  is  usually 
embedded  in  thick,  dense  connective  tissue. 

Sciatica. — Ischias  (that  is,  neuralgia  of  the  sciatic  nerve)  is  charac- 
terized by  pains  radiating  from  the  thigh  to  the  calf.  Typical  painful 
points  are  found  at  the  exit  of  the  sciatic  plexus  from  the  great  sciatic 
notch,  about  the  tuber  isclhi,  on  the  posterior  surface  of  the  thigh,  in 
the  fold  of  the  buttock,  helow  the  head  of  the  fibula,  and  behind  the 
internal  malleolus.  The  cause  is  usually  an  acute1  inflammation  of 
the  nerve-sheath  with  adhesions  and  thickening  following  a  cold.  To 
prevent  the  pain,  the  limb  is  guarded  and  movement  carefully  avoided. 
As  a  result  of  this  effort  to  protect  the  painful  spots  contractures  are 
not  rare,  of  which  the  author  would  emphasize  the  peculiar  constrained 
position  of  the  body  termed  ischiatic  scoliosis. 

Treatment.  —  The  treatment  consists  chiefly  in  massage,  gymnastics, 
and  electricity.  The  back  of  the  hip  and  thigh  are  massaged  twice  daily 
and  active  motion  and  finally  passive  motion  are  carried  out  to  stretch 
the  nerve  as  much  as  possible  and  loosen  any  adhesions.  This  procedure 
is  very  painful  at  first,  but  the  affection  yields  rapidly,  so  that  even  in 
old  cases  recovery  can  be  brought  about  in  a  few  weeks. 

Stretching  the  sciatic  nerve  is  usually  very  beneficial.  The  thigh  is 
flexed  as  far  as  possible  with  the  leg  extended,  or  the  leg  is  alternately 
flexed  and  extended  as  far  as  possible  with  ilie  'high  flexed.  The  patient 
should  walk  as  much  as  possible  during  the  treatment.  Electricity, 
baths,  and  daily  stool  are  valuable  aids.  Morphine  is  often  necessary; 
subcutaneous  injection  of  cocaine  or  antipyrin  into  the  nerve  often  give 
great  relief.  Operative  stretching  of  the  nerve1  is  indicated  for  severe 
cases  resisting  conservative  treatment.  Ilolscher  has  recently  recom- 
mended exposing  the  nerve  as  it  emerges  from  the  pelvis  and  applying 
wet  compresses  of  5  per  cent,  carbolic-acid  solution  for  several  days. 
The  result  is  said  to  be  good  and  permanent. 


INFLAMMATORY  PROCESSES  IN  THE  FEMUR. 

Acute  Osteomyelitis. — Acute  "  spontaneous  "  osteomyelitis,  according 
to  Haaga's  statistics  of  440  cases  in  v.  Brims'  clinic,  affects  the  thigh  in 
39  per  cent,  of  all  cases.  The  site  of  choice  is  the  lower  (aid.  Accord- 
ing to  Lexer's  recent  investigations,  it  is  commonly  a  staphylococcus,  less 
frequently  a  streptococcus  infection.     Staphylococcus  aureus  or  ulbus  is 


552  DISEASES  OF  THE  THIGH. 

found  in  the  mild  cases;  the  streptococcus  alone  or  with  the  staphylo- 
coccus in  severe  cases.  The  point  of  entrance  of  the  bacteria  is  either 
a  small  suppurating  wound,  acne  pustule,  furuncle,  panaritium,  eczema, 
abscess,  etc.,  or  an  abrasion  in  the  mucous  membrane  of  the  mouth  or 
nose,  especially  an  inflamed  spot  in  the  nose  or  on  the  tonsil.  This  point 
of  entrance  is  unknown  in  only  a  small  percentage  of  the  cases;  it  is 
then  supposed  to  be  in  the  respiratory  or  intestinal  tract.  Recently 
Ponfick  has  shown  that  infection  may  occur  through  the  mucous  mem- 
brane of  the  middle  ear.  Trauma  unquestionably  plays  an  important 
part,  as  bacteria  settle  chiefly  in  bruised  tissue,  the  point  of  least  resist- 
ance. The  disease  occurs  most  frequently  between  the  eighth  and 
seventeenth  years,  the  period  of  most  active  growth,  and  is  rare  in  early 
childhood  or  middle  life.  Men  are  more  commonly  affected  than 
women  (4  to  1). 

Symptoms. — The  symptoms  are  those  of  a  severe  septic  infection,  and 
vary  according  to  the  intensity  of  the  process.  In  acute  cases  there 
is  usually  an  initial  chill  and  rapidly  increasing  severe  pain,  swelling, 
and  high  continuous  fever:  in  the  morning  102.2°  to  104°  F.,  in  the 
afternoon  104°  to  105.8°  F.  The  swelling  increases  rapidly  and  becomes 
cedematous  with  a  diffuse  redness  about  the  hip.  Gradually  superficial 
fluctuation  develops,  and  spontaneous  rupture  occurs,  as  a  rule,  in  about 
fourteen  days. 

The  local  symptoms  ordinarily  point  early  to  a  disease  of  the  bone. 
On  the  other  hand,  if  the  patient  is  in  a  condition  of  complete  stupor, 
typhoid  may  be  suspected  until  the  local  symptoms  are  distinct.  Con- 
fusion with  severe  phlegmon  is  less  possible,  as  in  osteomyelitis  the 
uniformly  hard  cedematous  swelling,  surrounding  the  entire  hip  and 
disappearing  very  suddenly,  is  characteristic.  (Konig.)  If  less  acute, 
a  rapidly  growing  tumor  or  tuberculosis  may  be  suspected.  Kiittner 
has  recently  called  attention  to  the  occurrence  of  a  primary  tuberculosis 
of  the  shaft. 

From  its  proximity  to  the  joint  there  is  almost  always  an  osteochon- 
dritis of  the  epiphysis  followed  by  inflammation  of  the  joint,  either 
serous  or  purulent,  or  separation  of  the  epiphysis.  Foci  in  the  epiphysis 
may  perforate  directly  into  the  joint  or  even  through  the  knee-joint 
into  the  tibia. 

The  severest  cases,  with  fever  like  that  of  typhoid,  severe  septic  infec- 
tion, separation  of  the  epiphysis,  suppuration  of  the  knee-  or  hip-joint, 
and  involvement  of  a  large  part  of  or  the  entire  shaft  are  almost  always 
fatal.  Almost  regularly  part  of  the  bone  is  destroyed  and  a  sequestrum 
formed.  The  separation  of  the  periosteum  and  purulent  infiltration  of 
the  medulla  cause  more  or  less  extensive  necrosis  of  the  bone,  either 
superficially  in  plates  or  scales  (cortical  sequestrum)  or  of  large  portions 
of  the  compacta  and  spongiosa.  Often  the  entire  thickness  of  the  shaft 
becomes  necrotic  and  the  whole  shaft  forms  a  sequestrum  (total 
necrosis),  or  there  may  be  multiple  spots  of  necrosis  (necrosis  dis- 
seminata). (Fig.  357.)  The  larger  sequestra  generally  separate  in 
about    three    months.     The   separation   of    the   sequestrum,    although 


INFLAMMATORY  PROCESSES  IS  THE  FEMUR. 


553 


often  difficult   to   determine,   is   presumed    it*   the   granulations   bleed 

easily.  It  may  not  be  possible  to  move  the  sequestrum  with  the 
probe  if  it  is  held  by  points  projecting  into  the  wall  of  the  bone.  A 
peculiar  sound,  cracked-pot,  as  Konig  calls  it,  may  be  elicited  by  probing. 


Fig.  357. 


vj- 


Fig.  358. 


Necrosis  of  the  femur  at  the  typical  spot, 
(v.  Bruns.) 


General  necrosis  of  the  femur  with 
numerous  fistulas.  (v.Yolkmann.) 


The  separation  in  some  cases  is  determined 
by  the  .r-ray,  in  others  only  on  operation. 
(Fig.  358.)  Removal  at  the  proper  time  is 
very  important:  if  undertaken  too  early,  the 
formation  of  new  bone  may  be  limited  and 
pseudarthrosis  or  spontaneous  fracture  may 
occur;  on  the  other  hand,  long-continued 
suppuration  may  cause  chronic  nephritis  and 
amyloid  degeneration  of  the  viscera  and  death.  The  fistulas  usually 
open  outward  between  the  vastus  externus  and  biceps,  or  between  the 
vastus  interims  and  the  adductors. 

The  deformities  are  very  interesting.  The  shaft  may  be  bent  at  the 
upper  or  lower  end  or  in  the  middle.  At  the  upper  end  it  may  resemble 
coxa  vara  if  the  neck  is  involved.  The  deformity  may  be  marked. 
(Fig.  359.)  The  lower  end  is  apparently  more  frequently  affected,  as 
in  the  cases  reported  by  Oberst,  Kraske,  Mosetig,  Bofinger,  Braasch, 


554 


DISEASES  OF  THE  THIGH. 


Birch  and  Hirschfeld,  Karewski,  and  ScharfT.  In  all  these  cases  there 
was  a  very  characteristic  curvature  backward  or  inward  about  3  inches 
above  the  joint;  the  sequestrum  was  central,  as  verified  by  the  x-ray, 
and  usually  without  suppuration  and  perforation.  The  deformity  is 
due  apparently  to  muscular  action  and  the  weight  of  the  body.  The 
proliferation  of  bone  may  produce  complete  sclerosis,  or,  if  old  abscesses 
persist,  club-shaped  enlargements  of  the  shaft.  The  epiphyseal  growth 
may  be  stimulated  and  the  femur  lengthened.  The  discharge  of  large 
sequestra  may  produce  shortening.  Total  necrosis  of  the  entire  shaft 
causes  the  greatest  deformity,  with  shortening  and  an  abnormal  position 
of  the  lower  portion  of  the  limb. 

Fig.  359. 


Curvature  of  the  upper  end  of  the  femur.     (Oberst.) 


Treatment. — Usually  the  treatment  is  purely  surgical.  At  the  onset, 
aside  from  general  measures,  stimulants  and  nourishing  diet,  absolute 
rest  should  be  enforced,  the  limb  immobilized  with  a  strip  splint,  and 
ice  applied  to  diminish  pain.  Early  drainage  should  be  secured  by  free, 
and  if  necessary,  multiple  incisions,  and  the  bone  examined  carefully. 
If  the  periosteum  is  intact,  the  wound  is  simply  drained ;  if  the  periosteum 
is  lifted  off  by  pus  and  the  exposed  bone  beneath  is  filled  with  yellow 
spots,  the  latter  should  be  incised  as  far  as  diseased,  the  diseased  medulla 
scraped  out,  and  the  cavity  packed  with  iodoform  gauze.  If  this  is  done 
in  time,  necrosis  and  involvement  of  the  joint  may  be  prevented. 

The  sequestrum  should  be  removed  under  application  of  the  Esmarch. 
The  bone  is  exposed  through  a  free  incision  and  opened  either  by  widen- 
ing the  existing  opening  or  by  chiselling  off  a  sufficiently  large  "lid"  of 
the  "coffin"  to  expose  the  sequestrum.  Often  considerable  bone  has  to 
be  cut  away  in  order  to  seize  and  extract  the  sequestrum.  If  the  seques- 
trum is  large,  the  walls  of  the  "coffin"  should  be  chiselled  away  till 


TUMORS  OF  THE  THIGH.  555 

every  part  of  the  cavity  is  exposed  and  can  be  thoroughly  cleansed  of 
sequestra,  granulations,  and  pus.  Although  this  often  makes  very  large 
hone  cavities  with  sloping  walls,  into  which  the  soft  parts  are  implanted 
with  difficulty,  and  which  require  a  long  time  to  heal  over,  nevertheless 
the  method  is  usually  successful.    (See  also  p.  702.) 

The  implantation  of  organic  or  inorganic  material  has  not  given  very 
good  results.  Small  cavities  may  be  blood-clotted  by  Schede's  method. 
Recently  Schulten  recommended  implanting  a  pedunculated  muscle- 
periostenm  flap  after  careful  removal  of  all  granulations.  If  the  seques- 
trum is  in  the  lower  epiphysis,  Liicke  implants  the  patella.  If  the 
process  is  close  to  the  knee-joint,  in  spite  of  all  treatment  fistulas  may 
persist  and  amputation  be  necessary  to  prevent  a  fatal  termination  of 
the  suppuration  and  cachexia. 

TUMORS   OF   THE  THIGH. 
Tumors  of  the  Femur. 

Cystic  Chondrofibroma.—  Of  the  tumors  of  the  thigh,  those  of  the 
femur  have  recently  claimed  the  most  attention,  especially  since  the  in- 
vestigations conducted  under  v.  Bergmann.  Surgeons  have  thus  become 
familiar  with  the  nature  and  diagnosis  of  a  class  of  tumors  formerly 
little  regarded,  but  extremely  significant  for  the  differential  diagnosis, 
the  cystic  chondrofibromata.  These  tumors  vary  greatly  in  size,  but 
their  situation  is  constant  and  significant  for  the  differential  diagnosis. 
Thev  usually  start  close  under  the  trochanter,  in  the  region  of  the 
transition  cartilage.  Occurring  in  the  majority  of  cases  in  youthful 
subjects,  they  lead  gradually  and  steadily  with  palpable  thickening  of 
the  bone  to  curvature  and  corresponding  shortening  of  the  femur.  On 
opening  the  bone  at  the  curvature  a  softening  cyst  of  the  medulla  and 
cortex  is  usually  found,  about  the  size  of  a  hazelnut,  sharply  defined, 
extending  into  the  neck,  and  of  fibrocartilaginous  consistence.  If  not 
removed,  spontaneous  fracture  may  occur  ultimately. 

In  rare  instances  the  cystic  chondrofibroma  reaches  the  dimensions 
usually  attained  only  by  sarcoma ;  in  a  case  of  v.  Bergmann's  the  tumor 
extended  from  the  head  to  the  middle  of  the  femur.  In  the  larger 
tumors  there  are,  as  a  rule,  several  larger  or  smaller  cysts  with  smooth 
walls  and  containing  brownish  material;  they  are  to  be  regarded  as 
necrotic  masses  of  the  tumor.  The  surrounding  bone  is  generally  very 
thin,  often  compressible,  and  slightly  fluctuating,  a  symptom  which 
facilitates  the  diagnosis  if  the  tumor  is  large.  Even  without  this  symp- 
tom the  site,  gradual  growth,  the  curvature,  and  shortening  are  against 
sarcoma.  In  the  cases  known  in  the  literature  excision  with  the  chisel 
and  sharp  spoon  brought  about  recovery  without  recurrence.  The 
curvature  is  overcome  by  fracturing  the  bone. 

Enchondroma. — Enchondroma  also  occurs  in  the  thigh,  and  like  the 
above  is  to  be  regarded  as  a  growth  from  a  portion  of  unossified  cartilage 
separated  from  the  bone  at  the  normal  point  of  ossification. 


556  DISEASES  OF  THE  THIGH. 

Chondroma. — Cartilaginous  exostoses  are  etiologically  related  to 
the  above,  developing  either  as  a  local  manifestation  of  a  general  growth 
of  exostoses  or  occurring  alone  near  the  epiphysis,  usually  the  lower. 
A  bursa  containing  fluid  similar  to  synovial  fluid  not  infrequently 
develops  over  the  exostoses  (exostosis  bursata).  Their  removal  is  only 
indicated  if  they  are  troublesome. 

Fibroma. — Fibroma  is  rare  and  is  usually  periosteal  in  the  form  of 
nodules;  occasionally  they  also  contain  bone,  and  are  then  partly 
attached  to  the  femur,  "osteofibroma."  Transition  forms  occur  here 
as  elsewhere;  it  is  often  difficult  to  distinguish  fibroma  from  sarcoma. 

Myxoma. — The  periosteal  form  is  a  round  tumor  covered  with  con- 
nective tissue;  the  myelogenous  forms  are  destructive,  and  form  cysts 
by  liquidation  of  the  parts  involved.  In  rare  instances  the  growth  has 
been  located  simultaneously  in  the  medulla  and  periosteum. 

Lipoma. — Lipoma  of  the  shaft  belongs  to  the  rarities.  Power, 
Xannoti,  Quenu,  and  Walther  have  successfully  excised  congenital  peri- 
osteal lipoma  which  started  near  the  epiphysis  of  the  lesser  trochanter. 

Inflammatory  Osteoid  Tumors. — These  tumors,  which,  according 
to  Konig  and  Honsell,  develop  along  the  linea  aspira  after  trauma  to 
the  size  of  a  child's  head,  are  benign  and  can  be  removed,  like  the  above 
forms,  with  the  chisel. 

Sarcoma. — The  majority  of  tumors  of  the  shaft  are  sarcomata.  The 
myelogenous  variety  usually  starts  in  the  epiphysis,  less  frequently  in 
the  shaft.  As  the  lower  epiphysis  is  the  favorite  site  of  the  growth,  the 
latter  may  be  mistaken  for  a  joint-inflammation  at  the  outset,  but  its 
nature  is  finally  established  by  aspiration.  The  joint  is  usually  freely 
movable.  Suspicion  of  osteosarcoma  should  always  be  aroused  in  an 
apparent  joint-inflammation  by  the  dilatation  of  the  veins  of  the  skin 
over  the  joint.  This  is  always  caused  by  compression  of  the  deep  ves- 
sels, and  is  an  early  symptom  of  the  growing  tumor.  The  myeloid 
sarcomata  are  either  round-cell,  spindle-cell,  or  polymorphocellular; 
the  more  solid  tumors  contain  giant  cells  and  give. a  relatively  favorable 
prognosis.  Beginning  by  destroying  the  spongiosa,  myelosarcoma 
(osteosarcoma)  rapidly  distends  the  bone  and  forms  a  large  growth 
covered  by  a  shell  of  bone;  finally  the  shell  is  perforated  and  the  sur- 
rounding structures  attacked.  An  early  diagnosis  is  not  infrequently 
facilitated  by  spontaneous  fracture.  Occasionally  the  tumor  is  very 
vascular  and  may  be  mistaken  for  an  aneurism;  the  site  and  develop- 
ment give  criteria  for  the  proper  diagnosis. 

The  periosteal  varieties  occur  commonly  in  the  shaft  and  are  either 
round-cell,  spindle-cell,  or  polymorphous.  The  solid  spindle-cell  sar- 
coma at  first  has  the  appearance  of  a  fibroma  and  constitutes  the 
transition-form  to  the  latter;  it  develops  more  slowly  and  is  generally 
more  benign  than  the  other  related  varieties,  but  it  is  more  apt  to  recur, 
so  that  simple  excision  is  usually  insufficient.  The  softer  varieties, 
especially  round-cell  sarcoma,  develop  rapidly  and  are  apt  to  become 
metastatic.  The  majority  of  periosteal  sarcomata  are  spindle-cell  or 
polymorphocellular,  and  frequently  produce  bone  in  the  parts  adjacent 


TUMORS  OF  THE  THIGH.  557 

t<>  thier  point  of  origin;  if  bone  is  formed  in  the  rest  of  the  tumor  itself, 
the  surgeon  is  dealing  with  an  osteosarcoma,  or,  more  properly  desig- 
nated, an  ossifying  sarcoma. 

Treatment. — Formerly  amputation  or  exarticulation  was  performed 
for  large  myeloid  or  periosteal  sarcoma,  resection  being  regarded  as 
justifiable  only  for  fibrosarcoma  or  occasionally  giant-cell  sarcoma. 
Rapid  growth  is  certainly  an  indication  for  high  amputation  or  exarticu- 
lation; even  then  the  prognosis  is  bad.  On  the  other  hand,  the  greater 
range  of  conservatism  has  been  demonstrated  by  Mikulicz,  who, 
encouraged  by  v.  Bergmann's  and  v.  Bramann's  success  in  resecting  the 
tibia,  performed  resection,  instead  of  a  more  radical  operation,  for  a 
periosteal  spindle-cell  sarcoma  involving  the  lower  third  of  the  femur. 
Mikulicz  excised  S  inches  of  the  lower  end  of  the  femur,  and  after 
being  sure  that  the  neoplasm  was  thoroughly  removed  sawed  off  the 
cartilaginous  surface  of  the  tibia  and  inserted  the  lower  end  of  the 
femur  in  a  hole  bored  in  the  upper  end  of  the  tibia.  Wiesinger  also 
recently  resected  3  cases  successfully. 

Carcinoma. — Carcinoma  is  seen  in  the  femur  only  by  metastasis.  On 
the  other  hand,  Goebel  recently  reported  an  adenocarcinoma  of  the 
femur  which  showed  the  structure  of  a  thyroid  gland  and  produced 
spontaneous  fracture. 

Echinococcus  of  the  femur  grows  gradually  to  considerable  size 
and  frequently  absorbs  the  bone.  Exogenous  cysts  are  often  scattered 
throughout  the  entire  femur,  the  intervening  bone  being  necrotic.  Such 
extreme  cases  require  radical  measures;  otherwise  the  cysts  may  be 
curetted  out  of  the  medulla  and  the  cavities  drained. 

Tumors  of  the  Soft  Parts. 

In  contrast  to  osseous  tumors,  the  majority  of  tumors  of  the  soft  parts 
are  situated  in  the  upper  third  of  the  thigh,  being  especially  common  in 
the  inguinal  region.  In  the  skin  and  subcutaneous  tissue  fibroma, 
lipoma,  fibrolipoma,  hemangioma,  carcinoma,  and  sarcoma  are  rela- 
tively frequent,  the  two  latter  starting  from  pigment  moles;  myxoma 
and  enchondroma  are  less  common;  osteoma  rare.  By  reason  of  their 
superficial  position  their  removal  is  as  simple  as  the  diagnosis. 

In  the  inguinal  region  lymphangioma  occurs  occasionally  in  the 
form  of  soft  tumors  even  as  large  as  the  fist ;  they  may  be  felt  as  a  chain 
of  nodules  beneath  the  finger.  Echinococcus  cysts  are  very  liable  to  be 
found  here  and  in  the  adductors,  and,  aside  from  their  slow  growth, 
occasionally  give  the  characteristic  hydatid  thrill.  Schrank  recently 
classified  the  cysts  occurring  in  the  groin.  Among  these  are  to  be  men- 
tioned atheroma,  retention-cysts  of  the  sweat-glands,  hygroma,  lymph- 
cysts,  dermoid  cysts.   Hydrocele  and  hematocele  are  described  elsewhere. 

The  inguinal  glands  may  be  affected  primarily  by  lymphosarcoma, 
the  tumor  becoming  adherent  to  the  large  vessels  and  jeopardizing  the 
entire  extremity.  Tuberculous  lymphomata,  although  rare,  are  similar 
to  the  tuberculous  glands  in  the  neck,  but  fortunately,  in  contrast,  rarely 


558  DISEASES  OF  THE  THIGH. 

involve  the  vessels.     Leukaemic  lymphomata  give  the  same  symptoms 
as  the  well-known  swellings  in  the  neck. 

The  inguinal  glands  may  be  involved  secondarily  by  sarcoma  of  the 
thigh,  scrotum,  uterus,  or  carcinoma  of  the  penis,  scrotum,  or  female 
sexual  organs,  etc.  Secondary  sarcoma  is  not  very  common;  secondary 
carcinoma  of  the  glands  only  too  often  nullifies  the  effect  of  the  original 
operation.  Recurrence  after  radical  removal  of  carcinomatous  or  sar- 
comatous glands  is  frequently  due,  as  correctly  emphasized  by  Lennan- 
der,  to  the  fact  that  adjacent  glands  were  overlooked;  he  has  therefore 
proposed  complete  removal,  in  one  operation,  of  the  glands  in  the 
groin  and  along  the  obturator  vessels  and  iliac  vessels  up  to  the  bifurca- 
tion of  the  aorta,  and  claims  that  there  is  no  danger  of  hernia.  The 
operation  is  described  on  page  560. 

In  the  differential  diagnosis  of  tumors  in  the  region  of  the  groin, 
simple  adenitis  I  bubo)  or  other  inflammations  are  almost  always  accom- 
panied by  general  symptoms;  a  gravitation  abscess  is  always  accom- 
panied by  the  characteristic  psoas-contracture;  aneurism  is  almost 
always  of  traumatic  origin.  Retroperitoneal  lymph-cysts  may  appear  in 
the  groin  as  fluctuating  tumors  the  size  of  a  fist  and  easily  be  mistaken 
for  a  gravitation  abscess.  (Narath.)  Strehl  reports  a  case  very  similar 
to  Xarath's,  which  proved  to  be  a  serous  tuberculous  gravitation  abscess. 

In  no  other  part  of  the  body  is  sarcoma  of  the  muscle  so  frequent  as 
in  the  thigh.  The  growth  is  almost  always  situated  near  the  adductors. 
The  fact  that  it  involves  the  fascia  lata  at  an  early  period  led  to  the  name 
sarcoma  of  the  fascia  lata,  whereas,  in  fact,  the  tumor  develops  from  the 
interstitial  connective  tissue  of  the  adductors.  Occasionally  the  origin 
is  in  the  vastus  interims  and  externus.  Thorough  removal  of  all  sus- 
pected tissues  is  imperative;  if  the  tumor  spreads  rapidly,  extensive 
dissection  is  sometimes  necessary;  if  diffuse,  thorough  resection  by 
Mikulicz'  method  or  amputation  may  be  required. 

A  myxoma  occasionally  develops  in  the  muscles,  is  easily  removed, 
but  very  often  recurs. 

The  nerves  of  the  thigh  may  be  the  seat  of  neurofibroma  with  a 
marked  tendency  to  develop  suddenly  into  sarcoma.  This  malignant 
tendency  is  shown  especially  by  congenital  multiple  neurofibromata  of 
the  various  nerve-trunks  (elephantiasis  nervorum  of  P.  v.  Bruns);  at 
least,  in  numerous  instances  in  which  a  neurosarcoma  was  apparently 
solitary,  careful  examination  demonstrated  many  swellings  in  various 
nerve-trunks.  Usually  when  they  come  under  observation  the  tumors 
are  already  large.  Occasionally  they  are  sensitive.  There  may  be 
motor  disturbances  in  the  region  of  the  sciatic  nerve,  or  in  the  muscles 
supplied  by  one  of  its  branches,  or  sensory  disturbances.  If  the  tumor 
has  merely  flattened  the  nerve,  as  is  usual,  it  can  be  removed  without 
any  disturbance  of  innervation.  If  resection  is  necessary,  the  loss  is 
permanent  unless  the  nerve-stumps  can  be  sutured.  As  a  rule,  neuro- 
mata recur  either  locally  or  in  other  nerve-trunks,  and  then  show 
increased  malignancy  by  attacking  the  adjacent  tissues.  Internal 
metastasis  onlv  occurs  late  in  the  disease.     (Garre,  Hartmann.) 


CHAPTEE   XXIX. 

OPERATIONS  ON  THE  THIGH. 
LIGATION  OF  THE  FEMORAL  ARTERY. 

The  femoral  artery  runs  in  a  line  drawn  from  a  point  midway  between 
the  anterior-superior  spine  and  the  symphysis  to  the  back  of  the  internal 
condyle.  In  the  upper  third  of  the  thigh  the  artery  runs  through 
Scarpa's  triangle,  which  is  bounded  by  Poupart's  ligament,  the  sarto- 
rius  and  pectineus,  the  artery  and  its  vein,  to  the  inner  side,  being 
enclosed  in  the  sheath.  The  vessels  lie  upon  the  fascia  lata,  the  con- 
tinuation of  the  iliac  fascia,  and  are  covered  by  skin,  superficial  fascia, 
and  the  falciform  process  of  the  fascia  lata,  a  triangular  layer  blending 
with  the  inner  wall  of  the  sheath  of  the  vessels. 

In  Scarpa's  triangle  the  femoral  artery  gives  off  the  superficial  epigas- 
tric and  the  two  external  pudic  arteries  directly  beneath  Poupart's 
ligament,  and  about  1\  to  2  inches  farther  down  at  the  apex  of  the 
triangle  the  large  profunda  artery,  running  backward  and  inward.  In 
the  upper  third  of  the  thigh  the  femoral  artery  lies  to  the  inner  side  of 
the  sartorius,  in  the  middle  third  is  covered  by  it,  and  in  the  lower  third 
lies  along  its  outer  border.  On  exposing  the  posterior  sheath  of  the 
sartorius  the  vessels  are  seen  beneath,  and  on  dividing  the  sheath  in  the 
middle  third  of  the  thigh  the  long  saphenous  nerve  is  found  lying  upon 
the  vessels.  In  the  lower  third  the  vessels  pass  through  Hunter's  canal 
and  enter  the  popliteal  space  at  a  point  about  3  inches  above  the  level 
of  the  upper  border  of  the  patella,  the  artery  at  this  point  lying  beneath 
the  vein. 

The  femoral  artery  can  be  ligated  anywhere  in  the  thigh  down  to  the 
point  where  it  passes  through  the  adductor  tendons.  Its  pulsation  can 
be  felt  from  Poupart's  ligament  to  the  junction  of  the  upper  and  middle 
thirds  of  the  thigh.  From  this  point  it  can  be  palpated  in  the  groove 
between  the  adductor  and  vastus  internus  by  seizing  the  thigh  with  the 
finger-tips  in  the  groove  and  pressing  against  the  bone.  The  preferable 
sites  for  ligation  are  in  Scarpa's  triangle,  in  the  middle  third,  and  at  the 
junction  of  the  middle  and  lower  thirds. 

Ligation  in  Scarpa's  Triangle  after  Larrey  (Tig.  360,  &).— An  incis- 
ion 2\  inches  long  is  made  down  to  the  superficial  fascia  in  the  direc- 
tion of  the  vessels.  The  fascia  is  divided  upon  a  director  and  the 
sheath  of  the  vessel  opened.  The  ligature  is  passed  between  the  artery 
and  vein  from  within  outward.  The  saphenous  vein  should  be  avoided; 
the  crural  nerve  lies  outside  of  the  field.  In  ligating  for  a  wound  or 
aneurism,  the  artery  is  tied  above  and  below  and  the  middle  piece 

(  559  ) 


560 


OPERATIONS  ON  THE  THIGH. 


Fig.  360. 


excised,  all  lateral  branches  from  the  latter  being  carefully  tied  pre- 
viously. 

Ligation  in  the  Middle  Third,  after  Bell  (Fig.  300,  c).— The  sartorius 
is  located  and  the  incision  made  at  its  inner  border.     The  artery  lies 

in  a  line  drawn  from  the  anterior-superior 
spine  to  the  internal  condyle.  After  exposing 
the  sheath  of  the  sartorius  the  muscle  is 
retracted  outward,  its  posterior  sheath  and 
the  sheath  of  the  vessels  opened,  meanwhile 
protecting  the  long  saphenous  nerve. 

Ligation  in  the  Adductor  Canal,  after 
Hunter  (Fig.  360,  d). — The  incision  is  made 
in  the  same  line  as  above,  and  along  the 
outer  border  of  the  sartorius,  the  muscle 
drawn  inward,  the  sheath  opened,  and  the 
artery  isolated  and  ligated.  Care  should 
be  taken  to  keep  in  the  adductor  canal  and 
not  seek  the  artery  too  deeply. 

Lennander's  Operation  to  Remove  the 
Inguinal  Glands  in  the  Groin  and  Along 
the  Iliac  and  Obturator  Vessels. — To  re- 
move the  glands  in  the  groin  and  along  the 
iliac  and  obturator  vessels,  Lennander  makes 
an  incision  from  the  symphysis  along  Pou- 
part's  ligament  to  the  anterior-superior  spine 
and  then  along  the  anterior  third  or  to  the 
middle  of  the  crest  of  the  ilium.  From  this 
incision  another  is  made  downward  on  the 
thigh  over  the  femoral  artery.  The  groin  is 
cleaned  out  in  the  usual  manner,  the  deep 
glands  between  the  superficial  and  deep 
femoral  vessels  also  being  removed.  Pou- 
part's  ligament  is  then  separated  from  the 
spine,  crest  of  the  pubis,  fascia  lata,  and  iliac 
fascia.  The  deep  epigastric  and  internal 
circumflex  iliac  vessels  are  double  ligated 
and  divided.  A  few  glands  usually  to  be 
found  at  the  proximal  part  of  these  vessels 
incisions  for  Hgating  the  external    are  sought  and  removed.     The  abdominal 

iliac  artery  (o)  and  the  femoral  ar-  muscles  are  divided  close  to  the  Crest  of  the 
terv  in  Scarpa  a  triangle  (o),  in  the      ...  .         .  .  ......  r™ 

middle  third  of  the  thigh  (c),  and  in  "lum  in  the  prolonged  _  skin  incision.  1  he 
Hunters  canal  (d).  (After  v.  wini-  peritoneum  is  lifted  off  in  the  iliac  fossa  and 
warter)  iii  the  adjacent  part  of  the  true  pelvis.    The 

vas  deferens  (round  ligament),  spermatic  vessels,  hypogastric  fold  (Liga- 
menta  vesico-umbilicale)  or  umbilical  artery,  and  the  ureter  follow  the 
peritoneum. 

The  glands  can  now  be  excised  en  masse  in  the  femoral  ring,  about 
the  external  iliac  vessels  to  the  bifurcation  of  the  common  iliac  artery 


d  — 


TRANSPLANTATION  OF  TENDONS.  561 

and  about  the  obturator  and  hypogastric  vessels.  By  lengthening 
the  incision  through  the  skin  and  muscles  along  the  crest  of  the  ilium, 
the  glands  along  the  common  iliac  vessels  may  be  removed  it'  necessary. 
A  drainage-tube  wrapped  in  gauze  is  inserted  up  to  the  iliac  vessels  in 
the  back  of  the  wound  or  broughl  out  in  the  lumbar  region  if  the  incision 
extends  far  back.  Another  drainage-tube  is  inserted  in  front  of  the 
iliac  vessels  up  to  the  obturator  vessels  and  brought  oul  through  the 
skin  beneath  Poupart's  ligament.  The  latter  is  sutured  carefully  back 
in  place,  and  the  abdominal  muscles  are  sutured  to  the  crest  of  the 
ilium,  leaving  a  sufficient  opening  behind  for  drainage. 

By  the  above  operation  the  abdominal  wall  is  injured  only  in  as  far  as 
the  peritoneum  is  separated  oil'  from  and  sutured  again  to  the  bone  and 
fascia.     No  motor  nerves  are  injured. 


OPEN  STRETCHING  OF  THE  SCIATIC  NERVE. 

Billroth  and  v.  Nussbaum  introduced  open  stretching  of  the  sciatic 
nerve;  it  is  employed  especially  for  sciatica,  paresis  and  neuralgia 
of  the  sciatic  due  to  adhesions,  and  a  few  of  the  spinal-cord  affec- 
tions (tabes  dorsalis).  Two  points  are  preferable  for  operation;  in 
the  gluteal  fold  and  above  the  popliteal  space.  In  the  gluteal  fold 
a  4\-inch  incision  is  made  downward  from  a  point  midway  between 
the  tuber  ischii  and  the  great  trochanter  and  at  the  level  of  the 
former.  The  gluteus  maximus  and  biceps  are  exposed  and  retracted; 
the  sciatic  nerve  lies  beneath.  The  sciatic  artery  accompanying  it 
is  protected;  the  nerve  is  drawn  from  its  sheath  and  stretched  above 
and  below  until  an  appreciable  lengthening  is  obtained.  The  wound 
is  packed  lightly.  Above  the  popliteal  space  the  nerve  is  found 
between  the  biceps  and  the  semimembranosus  and  tendinosus.  The 
nerve  is  easily  found  after  incising  the  skin,  subcutaneous  fat,  and 
superficial  fascia.  According  to  Schede  and  Xocht,  the  results  are 
very  favorable,  among  24  cases  21  recovering,  in  1G  the  improvement 
being  immediate  and  permanent.  Quenu  reports  a  case  of  sciatica 
due  to  numerous  varicosities  and  cured  by  their  removal.  Delageniere 
found  the  nerve  enclosed  by  a  thick  network  of  small  tortuous  veins, 
by  tearing  which  complete  recovery  was  effected. 

Various  other  nerves  have  been  stretched  or  resected  in  the  thigh. 
Lauenstein  excised  part  of  the  obturator  nerve  for  a  contraction  of  the 
adductors  of  central  origin.  Haenlein  removed  part  of  the  genito- 
crural  for  neuralgia.  The  same  operations  have  been  performed  on 
the  crural. 

TRANSPLANTATION  OF  TENDONS. 

Recently  the   tendons   have   been    transplanted   repeatedly  for  par- 
alysis of    single  muscles,  especially  in  infantile  paralysis.     Cases  are 
reported  of  suture  of  the  sartorius  to  the  tendon  of  the  paralyzed  quadri- 
Vol.  III.— 36 


562  OPERATIONS  ON  THE  THIGH. 

ceps;  the  result  was  fairly  good,  after  the  sartorius  had  been  strength- 
ened by  massage,  electricity,  and  gymnastics.  This  after-treatment  is 
very  important.  Lange's  method  of  using  the  flexors  to  replace  the 
extensors  has  proved  valuable.  Lange  divided  the  biceps  and  semi- 
membranosus at  their  insertions,  brought  the  tendons  forward,  united 
them  above  the  patella  and  connected  them  with  the  spine  of  the 
tibia  by  a  strong  silk  thread  carried  over  the  patella.  It  often  suffices 
to  suture  the  flexor  tendons  to  the  patella.     (F.  Krause.) 


AMPUTATION    OF  THE  THIGH. 

On  account  of  the  thick  muscular  covering  at  the  middle  of  the  thigh 
amputation  by  any  of  the  various  methods  gives  an  equally  good  cover- 
ing over  the  stump.  In  the  lower  part  of  the  thigh  the  oval  or  flap 
incision  is  better  than  the  circular  incision  on  account  of  the  position 
of  the  cicatrix ;  in  the  upper  part  of  the  thigh  the  oval  incision  is  best. 
According  to  the  level,  surgeons  distinguish  high,  intermediate,  supra- 
condyloid,  and  intracondyloid  amputation. 

In  high  amputation  the  handle  of  the  racket  or  oval  incision  (Fig.  343), 
on  the  outer  side  of  the  thigh,  is  carried  down  to  the  bone  and  permits 
the  same  to  be  exposed  subperiosteal^  to  the  point  of  removal.  The 
femoral  artery  and  vein,  profunda  artery,  comes  ischiadicse,  and  branches 
of  the  circumflex  are  to  be  ligated.  The  sciatic  and  crural  and  other 
large  nerves  are  drawn  out  and  cut  off  high  up. 

In  the  middle  third,  to  the  circular  incision  are  added  two  lateral 
longitudinal  incisions  to  aid  in  dissecting  back  the  flaps  if  the  muscles 
are  thick;  or  a  large  anterior  and  a  small  posterior  flap  are  made  and 
the  muscles  divided  straight  across.  In  thin  subjects  it  is  advisable  to 
form  lateral  flaps  from  the  sides  giving  the  thickest  muscles.  The  out- 
ward rotation  of  the  stump  occurring  occasionally  after  operation  is  due 
to  contraction  of  the  outward  rotators,  (v.  Winiwarter.)  If  the  stump 
is  short,  it  may  be  drawn  up  to  a  right  angle  by  the  flexors.  To 
strengthen  the  end  of  the  stump,  Bier  recommends  suturing  a  periosteal 
flap  over  it. 

In  amputating  above  the  condyles  an  oblique  or  flap  incision  is  made 
on  the  front  and  inner  aspect,  as  the  adductors  draw  the  thigh  forward 
and  inward  so  that  an  anterior  incision  would  bring  the  scar  too  much 
under  the  inner  edge  of  the  bone.  Spence's  large  anterior  and  small 
posterior  flap-method,  modified  by  Farabeuf,  is  much  used.  In  this 
also  the  anterior  flap  is  made  preferably  a  little  to  the  inner  side.  Gritti's 
osteoplastic  amputation  gives  an  excellent  stump:  An  anterior  curved 
incision  is  made  from  the  condyles  to  the  spine  of  the  tibia;  the  liga- 
mentum  patellar  is  divided  at  its  insertion  and  the  flap  containing  the 
patella  is  dissected  back.  A  posterior  flap  is  made  of  the  same  length. 
The  muscles  are  divided  close  above  the  condyles  and  the  femur  sawed 
off  |  inch  above  the  upper  margin  of  the  cartilage.  The  patella  is  then 
sawed  through  on  the  flat,  the  articular  half  removed,  and  the  anterior 


AMPUTATION  OF  THE  THIGH. 


563 


portion  together  with  the  flap  of  the  soft  parts  turned  up  and  back  upon 
the  surface  of  the  femur,  the  edge  of  the  patella  being  sutured  to  the 
periosteum  of  the  latter  and  to  the  deep  fascia. 

[ntracondyloid  amputation  was  uamed  after  Carden  and  Buchanan. 

In  children  Buchanan  simply  removed  the  lower  end  of  the  femur  in 
the  epiphyseal  line.  Carden  sawed  off  the  condyles  in  an  antero- 
posterior curve  and  obtained  an  excellent  rounded  stump;  he  made  an 
oblique  incision  beginning  on  the  posterior  surface  at  the  level  of  the 
epicondyles  and  curving  downward  and  then  forward  to  the  spine  of  the 
tibia.  The  skin  and  fascia  are  dissected  back  to  above  the  patella  and 
the  quadriceps  divided  down  to  the  synovial  sac;  the  latter  is  exposed 
and  dissected  from  the  bone  to  below  the  epicondyle,  without  opening 
the  joint.  A  curved  incision,  convex  downward,  is  then  made  above 
the  margin  of  the  cartilage,  passing  backward  below  the  epicondyles, 
dividing  the  attachments  of  the  lateral  ligaments  and  ending  trans- 


Fig.  361. 


Fig.  362. 


Ssabanejeff's  osteoplastic  operation. 


versely  behind  above  the  attachment  of  the  synovialis  above  the  con- 
dyles. The  lower  epiphysis  of  the  femur  is  sawed  off  in  an  antero- 
posterior curve  in  this  line  to  form  a  rounded  stump  and  the  soft  parts 
divided  behind. 

Recently  Ssabanejeff  proposed  an  osteoplastic  intracondyloid  ampu- 
tation preserving  part  of  the  front  of  the  tibia  in  the  anterior  skin-flap. 
(Figs.  361  and  362.)  After  incising  and  dissecting  back  the  skin  and 
fascia  a  bone-flap  is  sawed  from  the  front  of  the  tibia,  as  in  the  diagram, 
and  turned  up  against  the  surface  of  the  femur.  The  attachments  of  the 
sartorius,  gracilis,  and  biceps  are  thus  saved  and  the  end  of  the  stump  is 
covered  with  skin  and  bone  which  are  accustomed  to  pressure.  Djelitzyn 
modified  this  method  by  sawing  the  femur  and  tibia  off  at  an  angle  of 
45  degrees  to  the  long  axis,  including  the  head  of  the  fibula  and  the 
insertion  of  the  biceps  in  the  anterior  flap,  opening  the  knee-joint  from 
below  after  sawing  off  the  tibia  and  fibula,  and  then  forming  the  posterior 


564  OPERATIONS  ON  THE  THIGH. 

flap  and  ligating  the  vessels.  Jacobson  and  Abrashanow  further  modi- 
fied the  method  by  preserving  the  flexors  and  their  insertions. 

Jacobson  makes  a  racket  incision  beginning  in  the  popliteal  space, 
running  downward  and  forward  to  end  f  to  1^  inches  below  the  spine  of 
the  tibia.  The  popliteal  artery  is  ligated,  the  soft  parts  divided,  the 
biceps,  sartorius,  gracilis,  semimembranosus,  and  semitendinosus  being 
lifted  off  with  the  periosteum  from  the  bone.  The  gastrocnemius  and 
plantaris  are  divided,  the  joint  opened  from  behind,  dislocated  forward, 
the  bone-flap  sawed  off  as  in  Fig.  361,  the  sawn  surfaces  apposed,  the 
biceps  tendon  sutured  to  the  outer  margin  of  the  tibial  segment,  and 
the  other  tendons  sutured  to  the  stumps  of  the  gastrocnemius  and  plan- 
taris. The  wound  is  sutured  longitudinally.  Abrashanow  recom- 
mends a  large  posterior  flap  including  skin,  muscles,  and  periosteum 
if  the  flap  cannot  be  made  from  the  anterior  surface  of  the  leg.  In  the 
small  anterior  flap  are  included  the  patella  and  insertion  of  the  rectus, 
analogous  to  Gritti's  method.  The  results  of  Ssabanejeff's  method 
have  thus  far  been  very  good,  the  patient  kneeling  in  the  true  sense  of 
the  word  upon  the  tuberosities  of  the  tibia.  Hilgenheimer  recommends 
the  method  if  sufficient  flap  material  is  present,  otherwise  Gritti's  opera- 
tion.    If  this  is  not  possible,  Carden's  transcondyloid  method. 

Hoftmann's  prothesis  is  serviceable  to  replace  the  limbafter  amputating 
high  up  or  at  the  hip.  The  artificial  limbs,  as  first  constructed  by  Hoft- 
mann  for  an  eighteen-year-old  patient  with  total  congenital  defect  of 
both,  limbs,  were  made  so  that  the  line  of  gravity  fell  in  front  of  the 
knee-joint,  the  false  limb  thus  becoming  rigid  at  each  step  as  the  body- 
weight  was  thrown  upon  it.  The  limbs,  hinged  to  a  pelvic  brace, 
swung  forward  alternately  as  the  patient  lifted  one  side  of  the  pelvis 
and  then  the  other,  so  that  the  gait  was  hardly  noticeable.  The  arti- 
ficial limbs  of  Hoch  and  Hunzinger  in  Cologne,  and  of  Eschbaum  in 
Bonn,  made  according  to  the  directions  of  Busch  and  Trendelenburg, 
are  also  very  good. 

For  the  stump  after  amputation  lower  down  one  of  the  best  artificial 
limbs  is  that  of  Pfister,  of  Berlin,  highly  recommended  by  Ivarpinski 
and  Gollmer.  Very  much  the  same  pattern  is  constructed,  with  slight 
modifications,  by  Erfurth  and  Geffers;  Middendorf,  of  Minister,  in 
Westphalia,  has  devised  a  very  useful  leather  sheath  appartus.  Nyrop 
constructed  a  wooden  leg  with  a  flexible,  light  and  durable  leather  foot. 
In  America  the  artificial  limbs  of  Marks  and  Hudson  are  commonly 
worn.  At  the  Surgical  Congress  in  1902  Engels,  of  Hamburg,  demon- 
strated a  very  useful  artificial  limb  with  a  flexible  knee-joint. 


INJURIES  AND  DISEASES  OF  THE  KNEE 

AND  LEG. 

By  Oberakzt  Dr.  P.  REICHEL. 

INJURIES  AND  DISEASES  OF  THE  KNEE. 


CHAPTER   XXX. 

INJURIES  OF  THE  KNEE. 
CONTUSION  AND   SPRAIN  OF  THE  KNEE. 

Contusion  of  the  knee,  usually  due  to  a  direct  fall  or  blow,  although 
a  very  frequent  injury  and  commonly  combined  with  abrasion  of  the 
skin,  is  usually  without  further  significance  and  heals  without  medical 
treatment.  Severe  contusion  sometimes  causes  extensive  extravasation  of 
blood  in  the  loose  subcutaneous  tissue  with  ecchymosis  and  diffuse 
swelling  of  the  soft  parts;  usually  the  blood  is  rapidly  and  entirely 
absorbed. 

An  effusion  of  blood  in  one  of  the  periarticular  bursa3,  most  frequently 
one  of  the  prepatellar,  is  absorbed  more  slowly.  The  characteristic 
situation  in  front  of  the  patella,  the  hemispherical  form,  and  fluctuation 
of  the  tumor  make  the  diagnosis  easy.  The  tumor  is  less  sharply  defined, 
however,  on  account  of  the  extravasation  in  the  subcutaneous  tissue 
than  in  chronic  bursitis.  As  in  the  joint,  the  blood  separates  into  clot 
and  serum.  If  the  bursa  ruptures  spontaneously  or  from  the  action  of 
the  trauma  or  the  pressure  of  a  bandage,  the  blood  is  poured  out  into 
the  subcutis  and  is  absorbed  more  quickly. 

Rosenberg  has  seen  several  cases  of  "riders'  pain  of  the  patella,"  due 
to  the  pressure  of  tight  riding-breeches,  in  which  there  was  severe  or 
almost  unendurable  pain  produced  by  the  slightest  pressure  against  the 
inner  border  of  the  patella.  It  usually  occurred  in  young  subjects  other- 
wise healthy-  The  objective  finding  was  negative.  Rest,  removal  of 
the  pressure,  and  cold  compresses  alleviated  the  pain;  recovery  required 
several  weeks.  The  wearing  of  looser  breeches  is  the  first  requisite  to 
prevent  recurrence. 

Contusion  acquires  greater  significance  if  the  joint  is  involved.  In 
this  case  the  capsule  and  ligaments  are  often  sprained  or  torn  slightly. 
Hemorrhage  then  takes  place  into  the  joint,  primary  ha?marthrosis,  and 
later  there  is  increased  secretion  of  synovia,  namely,  a  secondary  serous 

(565  ) 


566  INJURIES  OF  THE  KNEE. 

synovitis.  The  amount  of  hemorrhage  usually  corresponds  to  the  severity 
of  the  trauma;  in  rare  instances  slight  injury  is  followed  rapidly  by  pro- 
fuse hemorrhage  distending  the  capsule  almost  to  bursting.  Clinical 
experience  has  shewn  that  the  blood  may  remain  fluid  for  a  long  time — 
even  three  weeks — although  coagulation  commonly  occurs  after  the  first 
few  days.  The  time  at  which  coagulation  occurs  depends  apparently 
not  so  much  upon  the  duration  of  the  exudation  as  upon  the  nature  and 
severity  of  the  injury,  beginning  early  in  cases  of  extensive  laceration 
of  the  capsule,  especially  if  associated  with  fracture  of  the  patella  or  of 
the  joint-surfaces,  and  starting  at  the  point  of  injury;  so  the  blood-clot 
is  usually  attached  firmly  to  the  tear  in  the  capsule  or  at  the  point  of 
fracture  of  the  patella  or  of  the  surfaces  of  the  joint. 

Diagnosis. — In  simple  sprains  the  skin  is  at  first  unchanged  over  the 
injured  joint,  later  becoming  more  or  less  ecchymotic.  Ecchymosis  at 
the  onset  denotes  contusion  or  extensive  laceration  of  the  capsule. 
Ecchymosis  may  occur  later  from  spontaneous  rupture  of  the  distended 
capsule,  most  frequently  in  the  upper  recess,  and  reach  to  the  groin. 
This  aids  and  hastens  the  resorption  of  the  blood,  and  is  therefore 
per  se  not  so  undesirable. 

Hremarthrosis  is  characterized  by  rapid  distention  of  the  capsule  after 
the  injury;  the  longitudinal  furrows  at  the  sides  of  the  patella  are  oblit- 
erated, the  line  of  the  capsule  becomes  more  pronounced,  especially 
above  the  patella.  The  patella  is  lifted  from  the  condyles,  as  in  synovitis, 
and  the  patellar  click — "dancing  of  the  patella" — can  be  elicited  if  the 
tension  is  not  too  great.  According  to  the  absence  or  presence  of  coagu- 
lation, the  swelling  fluctuates  or  is  more  or  less  doughy  and  gives  the 
so-called  "snow-ball  crunching"  on  pressure.  If  the  soft  parts  about 
the  joint  are  severely  contused,  the  articular  swelling  is  more  or  less 
obscured.  Motion  is  more  or  less  painful  and  limited.  The  knee  is 
held  slightly  flexed. 

The  difficulty  of  diagnosis  lies  not  so  much  in  demonstrating  a  joint 
injury  as  in  excluding  complications,  separation  of  small  fragments  of 
cartilage  or  bone,  avulsion  or  dislocation  of  a  meniscus,  all  of  which 
occur  more  frequently  than  the  inexperienced  suppose.  Careful  palpa- 
tion and  the  use  of  the  ;r-ray  are  the  only  protection  against  the  occa- 
sionally serious  and  protracted  functional  disturbance  caused  by  such 
undiagnosed  complications. 

Prognosis. — Simple  contusion  not  involving  the  joint  usually  yields 
rapidly  with  moderate  elevation,  application  of  wet  dressings,  and 
massage.  Abrasions  of  the  skin  or  laceration  extending  into  the 
subcutis  or  the  proximity  of  a  furuncle  are  liable  to  cause  infection  of 
the  bruised  tissues  and  lead  to  extensive  phlegmon  about  the  knee  and 
along  the  thigh,  and  may  threaten  the  limb  or  life  of  the  patient.  There 
is  every  reason  therefore  to  treat  all  such  slight  wounds  accompanying 
contusion  of  the  knee  according  to  all  the  rules  of  asepsis.  Occasionally 
contusion  of  the  bursa  causes  a  serous  exudation  in  the  sac;  repeated 
slight  injury  may  give  rise  to  a  chronic  bursitis.  Contusion  or  sprain 
of  the  knee-joint  usually  recovers  fully  if  properly  treated.     Improper 


COXTUSlOy  AND  SPRAIN  OF  THE  KNEE.  557 

treatment,  insufficient  protection  at  the  outset,  is  not  infrequently  the 
reason  for  the  transition  of  a  primary  acute  serous  synovitis  into  a  chronic 
hydrops  with  relaxation  of  the  capsule,  loose  joint,  and  severe  functional 
impairment.  Partial  stiffness,  especially  in  elderly  individuals,  may 
follow  the  injury;  usually  it  is  due  to  protracted  immobilization.  In  a 
few  instances  the  injury  has  been  followed  by  a  deforming  inflammation 
of  the  joint.  The  influence  of  predisposition  is  still  an  open  question. 
It  is  certain  that  such  a  predisposition,  especially  hereditary,  favors  the 
development  of  tuberculosis  in  the  contused  or  sprained  joint,  hut  more 
frequently  in  children  than  in  adults.  Suppuration  of  the  joint  following 
a  simple  Mil 'cutaneous  injury  is  very  rare. 

Treatment. — In  mild  cases,  rest  for  a  few  days  and  compression  are 
sufficient.  Severe  injuries  with  evident  effusion  are  preferably  im- 
mobilized for  a  few  days  in  a  strip  splint.  Further  measures  depend 
chiefly  upon  the  amount  of  articular  hemorrhage;  its  rapid  and  complete 
removal  is  important  for  the  functional  restoration  of  the  joint.  The 
longer  a  blood-clot  remains  in  a  joint  the  more  it  favors  chronic  serous 
exudation  or  prolonged  stiffness.  Resorption  is  aided  by  pressure, 
moisture,  and  warmth.  The  joint  is  wrapped  in  a  wet  dressing  of  2  per 
cent,  aluminum  acetate  covered  with  rubber  tissue  or  wax  paper,  and 
bandaged  in  a  Yolkmann  splint. 

The  elastic  compression  of  a  rubber  bandage  acts  more  energeticallv; 
the  limb  should  be  supported  in  a  tin  gutter-splint,  with  a  cotton  pad 
under  the  knee  to  prevent  pressure  upon  the  popliteal  vessels,  and  the 
elastic  bandage  applied  over  the  knee  and  splint.  Excessive  compression 
is  therein-  impossible.  The  bandage  should  not  be  applied  too  tightly, 
and  should  be  changed  daily,  at  each  change  the  knee  and  muscles  of 
the  thigh  being  massaged  carefully  but  thoroughly  for  five  to  ten  minutes 
and  slight  movement  of  the  knee  carried  out  passively.  If  the  bandage 
is  too  tight  the  pain  becomes  unendurable;  if  properly  applied  the  con- 
tinuous elastic  compression  causes  the  effusion  of  blood  to  be  resorbed 
with  striking  rapidity.  Moderate  effusions  are  absorbed  in  this  man- 
ner in  from  eight  to  ten  days.  The  splint  can  often  be  left  off  after  a 
few  days,  but  the  joint  should  be  wrapped  in  flannel  for  some  time. 

The  question  as  to  how  long  to  immobilize  and  how  energeticallv  to 
carry  out  the  movements  will  depend  upon  the  sensitiveness  of  the  joint 
and  the  amount  of  effusion.  In  general,  immobilization  should  not  be 
continued  more  than  six  to  ten  days.  Massage  and  early  motion  mate- 
rially aid  the  resorption  of  blood  and  serum,  especially  in  young  other- 
wise healthy  patients.  The  joint  should  not  be  encumbered  by  walking 
too  early.  If  the  contusion  or  sprain  of  the  joint  is  at  all  severe,  the 
patient  should  not  be  about  until  several  days  after  the  effusion  has 
disappeared  entirely  and  remains  absent  in  spite  of  active  and  energetic 
movement  of  the  knee  in  bed.  A  bandage  or  elastic  knee-cap  should 
be  worn  for  some  time.  The  effusion  often  returns  on  walking;  if 
moderate,  massage  and  exercise  are  not  interrupted;  it  soon  disappears. 
If  it  increases  or  inflammatory  symptoms  appear,  rest  and  pressure 
should  be  enforced  for  a  short  time. 


568  INJURIES  OF  THE  KNEE. 

Large  effusions  or  large  hemorrhages  in  the  joint  which  do  not  yield 
to  treatment  should  be  aspirated  early,  and  if  necessary  a  small  incision 
made  and  sutured  again.  Statistics  prove  that  such  interference  gives  a 
shorter  course  of  recovery  and  a  more  complete  result.  Bondesen  gives 
the  average  period  of  recovery  with  aspiration  as  22.4  days,  without 
aspiration  38  days;  Lubbe,  in  32  cases  aspirated,  an  average  of  22.5 
days,  and  in  22  not  aspirated — although  these  were  mostly  mild  cases — 
34.6  days.  Bondesen  states  that  recovery  was  complete  in  86  per  cent, 
of  the  aspirated  cases  and  in  only  63  per  cent,  of  those  not  aspirated. 
For  aspiration  one  uses  a  trocar  and  canula  or  needle,  sterilized  by 
boiling,  sufficiently  large  to  remove  any  clots  or  fibrin.  If  the  blood 
does  not  flow  freely  the  joint  is  filled  with  sterilized  salt  solution  or  0.5 
to  1  per  cent,  carbolic  or  3  per  cent,  boric-acid  solution,  the  clots  broken 
up  by  careful  massage,  and  removed  by  thorough  irrigation.  The 
puncture  wound  is  closed  with  iodoform-collodion  or  sutured,  and  an 
aseptic  dressing  applied  with  slight  pressure  and  left  on  till  the  wound 
heals — about  6  to  8  days.  During  this  time  the  limb  is  immobilized  in 
a  tin  or  wire  gutter-splint.  The  rest  of  the  treatment  is  as  above.  The 
strictest  asepsis  is  unconditional.  If  it  cannot  be  carried  out,  it  is  better 
to  confine  the  treatment  to  compression  and  early  massage,  as  aspiration 
is  a  procedure  more  for  the  hospital  than  the  houses  of  poor  patients. 
Aspiration  or  incision  is  usually  performed  on  the  second  or  third  day 
after  the  injury.  Recovery  requires  several  weeks,  and  in  otherwise 
healthy  and  not  too  aged  patients  results  not  only  in  the  return  of  com- 
plete mobility  and  strength  of  the  joint,  but  also  in  a  permanent  cure 
without  the  danger  of  recurrence. 


WOUNDS  IN  AND  ABOUT  THE  KNEE-JOINT. 

The  common  abrasions  and  superficial  lacerations  of  the  skin  from 
falls  or  blows  upon  the  knee,  and  the  less  frequent  stab-,  incised,  and 
puncture-wounds  in  front  of  the  joint  from  sharp  or  pointed  instruments, 
have  little  significance  as  long  as  the  joint  is  not  involved.  Such  injuries 
on  the  posterior  surface  endanger  the  flexor  tendons,  tibial  and  peroneal 
nerve,  popliteal  artery,  and  short  saphenous  vein.  All  these  injuries 
are  rare,  and  their  diagnosis  made  simply  by  observing  the  situation 
of  the  wound  and  the  functional  disturbance.  Their  treatment  is 
on  general  principles.  Any  necessary  suture  of  tendons  or  nerves,  or 
ligation  of  bleeding  vessels,  is  facilitated  by  applying  the  Esmarch. 

Wounds  of  the  joint  or  about  the  joint  have  acquired  especial  signifi- 
cance. To  a  certain  extent  the  puncture-wounds  produced  by  falling 
upon  a  nail  or  by  the  thrust  of  an  awl  are  typical;  so  also  the  incised 
wound  from  a  misstroke  of  an  axe.  Wounds  made  by  dagger-thrusts, 
glass,  or  bursting  machinery,  etc.,  are  less  frequent.  Involvement  of 
the  joint  is  manifested  by  exposure  of  the  cartilage,  discharge  of  syno- 
via, or  by  hsemarthrosis,  although  slight  wounds  of  the  joint  are  not 
always  followed  by  an  effusion  of  blood.     If  the  wound  is  not  large, 


WOUNDS  IN  AND  ABOUT  Till-:  KNEE  JOINT.  569 

these  symptoms  may  be  absent,  as  the  skin  and  capsule  are  easily  shifted 
upon  each  other  and  only  coincide  in  certain  positions.  It'  the  knee  is 
wounded  while  flexed,  the  opening  into  the  joint  is  completely  covered  in 
extension,  and  the  reverse.  This  is  significant  in  regard  to  primary 
infection,  secondary  infection,  and  recovery,  as  under  certain  circum- 
stances secondary  infection  may  not  involve  the  joint.  In  many 
instances  the  entrance  of  air  into  the  joint  during  motion  distends  the 
capsule  and  gives  a  tympanitic  percussion  note  easily  distinguishing 
the  condition  from  the  similar  contour  produced  by  acute  hajmarthrosis. 
The  air  is  rapidly  absorbed. 

In  the  absence  of  other  complications  the  significance  of  penetrating 
wounds  of  the  joint  depends  upon  infection.  Foreign  bodies — for 
example,  a  needle — often  give  rise  to  active  disturbance  by  wander- 
ing. Their  demonstration  and  removal  are  facilitated  by  the  .r-ray. 
Infection  may  cause  mild  serous  synovitis  or  the  severest  kind  of 
panarthritis.  To  probe  or  finger  the  wound  merely  to  determine 
whether  the  joint  is  opened  or  not  is  counterindicated  as  being  purpose- 
less even  under  antiseptic  precautions;  without  such  precautions  it  is 
thoroughly  reprehensible.  In  doubtful  cases  the  wound  should  be 
treated  as  a  joint-wound.  If  the  entrance  of  a  foreign  body  into  the  joint 
is  suspected,  probing  is  justifiable  after  thorough  disinfection;  but  even 
then  it  is  better  to  enlarge  the  wound  under  application  of  the  Esmarch. 
If  the  wound  is  clean,  with  no  signs  of  inflammation,  it  should  be 
sutured  without  drainage,  all  torn  tissues  being  excised.  If  infection  is 
apprehended,  the  wound  is  packed  with  iodoform  gauze.  Small  punc- 
ture-wounds, slightly  swollen  and  tender,  but  without  fever,  such  as  are 
caused  by  a  needle  or  nail,  often  yield  to  rest,  antiseptic  wet  dressings, 
and  slight  pressure.  If  there  are  signs  of  an  infectious  synovitis,  the 
treatment  is  the  same  as  that  given  later  for  acute  inflammations  of  the 
knee-joint. 

Gunshot-wounds  of  the  joint  require  special  consideration.  It  is 
easy  to  understand  how  grazing  shots  can  injure  the  capsule  alone, 
and  how  those  entering  at  right  angles  to  the  limb  can  perforate  the 
upper  recess  of  the  capsule  or  the  space  below  the  patella  between  the 
ligament  and  the  tuberosities  without  injuring  the  joint-surfaces. 
Simon  was  the  first  to  show  by  experiments  on  the  cadaver  that  with 
the  knee  flexed  between  130  and  170  degrees  a  bullet  could  perforate 
the  joint  from  before  backward  without  touching  the  bones,  and  thus 
explained  the  favorable  course  of  many  shot-wounds  of  the  knee  with 
entrance  in  front  and  exit  behind  which  Stromeyer  regarded  as  contour- 
shots  on  account  of  their  occasionally  favorable  course. 

In  the  large  majority  of  cases  of  gunshot-wounds  of  the  knee  the 
bone  is  injured  more  or  less  severely.  Small-calibre  bullets  at  long 
range  frequently  produce  furrowed,  or  clean  perforating  wounds,  as 
seen  by  Kiittner  in  the  South-African  War,  whereas  at  moderate  range 
splintering  was  the  rule  in  the  compact  upper  end  of  the  tibia.  Shots 
at  close  range  cause  extensive  shattering  of  one  or  both  condyles  of  the 
femur  or  of  the  tuberosities  of  the  tibia,  often  with  considerable  splin- 


570  INJURIES  OF  THE  KNEE. 

tering  or  Assuring  of  the  shaft.  So  it  is  seen  that  they  still  produce  severe 
injuries,  although  the  prognosis  is  so  improved  by  modern  antisepsis 
that  the  statistics  of  former  wars  no  longer  apply. 

Kiittner  reports  hemorrhage  in  the  joint  as  constant  in  recent  gunshot- 
wounds  of  the  knee  even  with  mere  perforation  of  the  capsule.  In  one 
instance  pulsation  was  transmitted  directly  to  the  hsemarthrosis  from 
an  aneurism  of  the  popliteal  artery  communicating  with  the  knee-joint. 
Formerly  suppuration  was  the  rule,  so  that  in  all  severe  gunshot-wounds 
of  the  knee  primary  amputation  was  performed  by  many  surgeons  as 
the  best  mode  of  treatment.  It  was  after  the  war  of  1866  that  v. 
Langenbeck  first  called  attention  to  the  favorable  results  of  conservative 
measures  for  such  gunshot-wounds.  Still,  the  credit  is  due  to  v.  Berg- 
raann  of  having  demonstrated  not  only  the  qualifications  of  conserva- 
tive treatment  as  aided  by  antisepsis,  but  also  its  superiority  as  based 
upOn  his  experience  in  the  Russian-Turkish  War.  Of  15  gunshot 
fractures  of  the  knee-joint  cleansed  superficially  with  carbolic  acid, 
wrapped  in  10  per  cent,  salicylated  cotton,  and  immobilized  in  a 
plaster-splint,  14  recovered,  mostly  without  suppuration.  By  means  of 
primary  antisepsis  Reyher  obtained  a  movable  joint  in  15  of  18 
gunshot-wounds  of  the  knee.  The  results  of  conservative  treatment 
of  small-calibre  wounds  of  the  knee  in  the  South-African  War  were 
surprisingly  favorable.     (Kiittner,  MacCormac.) 

Such  results  are  conditional  upon  the  wound  being  touched  only  by 
fingers,  instruments,  and  gauze  which  are  carefully  sterilized,  v.  Berg- 
mann  recommends  that  on  the  battlefield  the  wound  should  not  be  dis- 
turbed, but  be  covered  with  iodoform  or  iodoform  gauze,  a  padded  splint 
applied,  and  the  patient  transferred  as  soon  as  possible  to  the  nearest 
field  hospital.  In  the  absence  of  signs  of  infection  the  treatment  here 
should  also  be  conservative  and  expectant.  Suppuration  calls  for  incision 
or  resection  and  the  removal  of  bone  splinters  and  foreign  bodies.  Exten- 
sive laceration  of  the  bone  and  soft  parts  caused  by  bomb-shell  frag- 
ments or  shots  at  close  range  requires  primary  or  secondary  amputation. 


INJURIES  OF  THE  POPLITEAL  VESSELS. 

As  the  large  popliteal  vessels  are  protected  by  their  deep  situation, 
injuries  of  the  same  are  seen  chiefly  as  complications  of  other  injuries, 
namely,  crushing  of  the  knee  in  runover  or  railroad  accidents,  less 
frequently  puncture-  or  gunshot-wounds.  Subcutaneously  the  vessels 
are  injured  by  fracture  splinters  or  are  ruptured  in  complete  backward 
dislocation  of  the  tibia.  If  ruptured  or  crushed,  the  involution  of  the 
intima  may  prevent  hemorrhage.  Usually  lesions  of  the  vessels  are 
followed  by  very  severe  hemorrhage;  if  the  injury  is  subcutaneous,  the 
extravasation  may  compress  the  veins,  cause  thrombosis,  and  endanger 
the  limb  if  not  checked.  Exceptionally  severe  contusion  produces 
rupture  of  the  inner  coats,  the  adventitia  remaining  intact,  and  leads 
to  the  formation  of  an  aneurism,  less  frequently  thrombosis.    In  v.  Bruns' 


FHACTriiKS  OF  THE  ('OXI)YLFS  OF  TJIF  FFMUR. 


571 


clinic  a  case  of  contusion  of  the  knee  without  injury  of  the  skin  was 
seen,  which  was  followed  by  gangrene  of  the  leg;  the  popliteal  artery 
was  found  to  be  thrombosed  and  both  inner  coats  ruptured.  Aneurism 
follows  small-calibre  gunshot-wounds  of  the  popliteal  artery  with  striking 
frequency. 

Unless  exceptional  circumstances  present  a  strict  counterindication 
the  injured  vessel  should  he  exposed  and  double  ligated  if  the  existence 
of  other  injuries  does  not  demand  amputation  at  the  knee-joint  or 
higher.  Single  ligation  of  the  femoral  artery  above  the  injury  has  been 
abandoned  as  being  uncertain.  The  few  reports  of  suture  of  the  vessel 
for  partial  division  of  the  artery  or  vein  have  been  favorable.  A  double 
row  of  continuous  sutures  is  made  with  fine  silk  or  linen  thread  and 
a  small  curved  needle;  the  first  row  includes  the  entire  thickness  of 
the  wall,  the  second  the  adventitia.  Lateral  ligation  or  suture  of 
the  vessel  is  only  advisable  if  the  patient  can  be  kept  under  constant 
observation. 


FRACTURES  OF  THE  CONDYLES  OF  THE  FEMUR  AND  OF  THE 
TUBEROSITIES  OF  THE  TIBIA. 


Fractures  of  the  Condyles  of  the  Femur. — Fractures  of  the  condyles 
are  very  similar  to  the  articular  fractures  of  the  lower  end  of  the  humerus. 
Transverse  supracondyloid  fractures  and  trau- 
matic separation  of  the  epiphysis  do  not  involve 
the  joint  primarily.  The  typical  forms  are  the 
oblique  fractures  of  one  or  both  condyles,  and 
the  T-  or  Y-fractures,  in  which  both  condyles 
are  separated  from  the  shaft  and  from  each 
other.  (Fig.  363.)  The  fragments  of  the  con- 
dyles are  usually  large  ;  less  frequently  small 
pieces  are  broken  off.  If  both  condyles  are 
broken,  the  lines  diverge  upward  to  end  above 
the  epicoiK Ivies.  Aside  from  these  typical  forms 
irregular  and  multiple  fractures  occur. 

The  cause  is  severe  violence,  direct  or  indi- 
rect, a  fall  or  blow  upon  the  knee  or  by  falling 
upon  the  feet  from  a  height.  Madelung  be- 
lieved that  T-  and  Y-fractures  were  produced  by 
a  wedge  action  of  the  patella,  but  Marcuse  pro- 
duced these  fractures  on  the  cadaver  after  re- 
moving the  patella.  Probably  Gosselin's  former 
theory  is  correct,  that  the  shaft  is  forced  between 
the  condyles  and  wedges  them  apart.     Forced 

abduction  or  adduction  of  the  leg  tears  off  the  lateral  ligaments  from  the 
bone,  but  does  not  produce  an  oblique  fracture  of  the  condyle. 

The  intra-articular  fractures  are  rapidly  followed  by  hemorrhage  into 
the  joint  which  conceals  the  otherwise  easily  palpable  contour  of  the 


T-fracture  of  the  condyles 
of  the  femur  due  to  a  fall 
upon  the  knee.     (v.   Bruns.) 


572  INJURIES  OF  THE  KNEE. 

bones.  The  functional  loss,  false  motion,  bony  crepitus,  and  typical 
displacement,  however,  are  usually  so  distinct  that  the  line  of  fracture 
can  be  rapidly  traced  out.  The  condyles  are  always  apt  to  be  dis- 
placed upward,  fracture  of  the  outer  condyle  giving  a  valgus  position - 
of  the  inner  a  varus  position.  T-  and  Y-fractures  increase  the  width  ot 
the  condyles  and  shorten  the  femur.  Passively  the  leg  can  be  abducted 
or  adducted.    The  fractured  condyles  can  be  shifted  upon  the  shaft. 

Prognosis. — The  prognosis  is  that  of  all  intra-articular  fractures. 
Partial  stiffness  may  persist,  extension  and  flexion  be  limited,  the  use 
of  the  limb  weak  and  uncertain,  and  combined  with  more  or  less  pain 
and  a  tendency  to  recurring  chronic  serous  synovitis.  Slight  dis- 
placement of  the  fragments  is  hardly  avoidable  as  exact  coaptation  is 
hindered  by  the  swelling  and  later  correction  is  impossible.  The 
resulting  unevenness  of  the  cartilaginous  surface  of  the  joint  disturbs 
the  normal  motion  of  the  tibia  upon  the  femur.  Arthritis  deformans 
may  follow.     Complete  restoration  of  function  is  rare. 

Treatment. — Aside  from  correcting  the  valgus  or  varus  position,  the 
blood  in  the  joint  should  be  removed  as  rapidly  as  possible  by  the  meas- 
ures previously  mentioned,  namely,  daily  renewal  of  wet  compresses  or 
a  rubber  bandage  and  immobilization  in  a  long  well-padded  Volkmarm 
splint;  also  early  massage  and  if  necessary  aspiration  with  or  without 
lavage  of  the  joint.  If  the  swelling  subsides  in  six  or  eight  days,  the 
limb  is  straightened  as  much  as  possible  and  immobilized  in  a  circular 
or  posterior  plaster-splint  if  only  one  condyle  is  broken.  The  splint  is 
removed  at  the  latest  in  two  weeks,  and  gentle  passive  motion  carried 
out  at  the  joint  with  massage  of  the  joint  and  muscles  of  the  leg  and 
thigh.  The  limb  is  then  immobilized  again  for  fourteen  days,  after 
which  the  plaster-splint  is  replaced  by  a  strip  splint.  It  is  even  better 
to  apply  the  strip  splint  earlier,  at  the  end  of  the  second  or  third  week, 
and  begin  massage  and  motion  as  soon  as  possible.  If  the  condyle  shows 
little  or  no  tendency  to  displacement,  immobilization  upon  a  simple 
strip  splint  may  be  sufficient. 

The  extension  treatment  is  preferable  for  Y-fracture,  as  otherwise  it 
is  difficult  to  prevent  the  upward  displacement  of  the  condyles  and  the 
resulting  shortening.  It  may  be  applied  on  the  first  day,  the  adhesive 
strips  reaching  to  the  middle  of  the  thigh;  it  does  not  prevent  any 
necessary  treatment  of  the  hoemarthrosis.  Extension  is  removed  as 
soon  as  the  callus  holds  the  fragments  and  a  plaster-splint  then  applied. 
On  account  of  the  greater  tendency  of  the  fragments  to  displacement 
movements  should  be  delayed  longer  than  in  the  case  of  oblique 
fracture  of  one  condyle. 

Fractures  of  the  Tuberosities  of  the  Tibia. — The  cause  is  the  same 
as  that  of  fractures  of  the  condyles  of  the  femur.  Often  there  is  merely 
a  fissure  in  the  head  of  the  tibia;  or  avulsion  of  smaller  or  larger  pieces 
of  the  marginal  cartilage  without  displacement;  or  there  may  be  an 
oblique  fracture  of  a  large  part  of  or  the  whole  of  one  tuberosity 
with  displacement  and  a  corresponding  varus  or  valgus  position;  or  the 
line  of  fracture  may  run  transversely  near  the  joint-surface,  the  upper 


FRACTURE  OF  THE  PATELLA. 


573 


corn- 
It  is 


Fig.  364. 


Fragment  being  intact  or,  more  commonly,  splintered.  If  the  fragment 
is  large,  it  is  liable  to  become  flexed  while  the  shaft  remains  extended. 
The  shaft  has  repeatedly  been  found  wedged  in  the  cleft  spongiosa  of 
the  head.    (Fig.  364.) 

A  typical  form,  typical  etiologically  and  anatomically,  is  the 
pression  fracture  of  the  head  of  the  tibia  described  by  Wagner. 
caused  by  falling  upon  the  feet  from  a  height, 
and  is  therefore  often  bilateral  or  accom- 
panied by  simultaneous  injury  of  the  other 
limb.  The  condyles  of  the  femur  drive  the 
menisci  into  the  spongiosa  of  the  tibia  and 
may  wedge  the  tuberosities  apart.  Usually 
the  inner  tuberosity  is  compressed  more  than 
the  outer,  although  either  may  be  injured 
singly. 

In  all  these  fractures  there  is  hemorrhage 
in  the  joint,  usually  profuse,  the  swelling  pre- 
venting accurate  palpation.  The  diagnosis 
is  therefore  often  difficult  and  can  only  be 
made  with  probability,  as  the  displacement 
may  be  slight  and  the  patient  able  to  walk, 
the  only  symptom  being  marked  local  ten- 
derness.    Usually,  however,  there  is  distinct 

false  motion,  crepitus,  characteristic  displacement,  varus  or  valgus 
position,  h  to  £  inch  shortening,  and  pronounced  broadening  of  the 
tuberosities. 

Treatment. — The  treatment  is  the  same  as  that  of  fracture  of  the 
condyles  of  the  femur,  rapid  removal  of  the  blood  in  the  joint,  extension 
for  fourteen  days,  then  a  plaster-splint  reaching  from  the  toes  to  the 
groin  and  motion  and  massage  as  early  as  possible,  at  the  latest  in  the 
sixth  wreek.  When  up  and  about,  a  removable  supporting  splint  of 
plaster  or  silicate  should  be  worn  for  a  few  weeks;  not  a  few  patients 
require  such  a  splint  for  many  weeks. 


Fracture  of  the  head  of  the  tibia 
with  impaction  of  the  shaft  in  the 
epiphysis.     (Hoffa.) 


FRACTURE  OF  THE  PATELLA. 


Fracture  of  the  patella  is  most  frequent  between  the  thirtieth  and 
fiftieth  year,  is  rare  before  the  twentieth  year,  and  is  almost  never  seen 
in  children  under  ten.  It  is  much  more  common  in  men  than  in  women. 
(88  per  cent.,  Rossi.)  It  represents  1.4  per  cent,  of  all  bone  fractures. 
(v.  Brims,  Rossi.)  One  distinguishes  simple  (subcutaneous)  and  com- 
pound, transverse,  longitudinal,  oblique,  and  comminuted  fractures.  By 
far  the  greater  number  of  simple  fractures  are  transverse.  (80  per  cent., 
Rossi.)  The  fracture-line  either  divides  the  bone  into  two  equal  frag- 
ments, an  upper  and  a  lower,  or,  more  commonly,  lies  below,  or  rarely 
bove,  the  middle  line.  (Fig.  3G5.)  Often  the  lower  end,  not  covered 
with  cartilage,  is  torn  off  alone,  rarely  the  upper  tip.   Malgaigne  and  Bahr 


574 


INJURIES  OF  THE  KXEE. 


have  demonstrated  that  the  line  is  usually  oblique  from  above  and 
without,  downward  and  inward,  rarely  the  reverse.     Cases  of  twofold 

or  even  threefold  transverse  fracture  are  reported,  the  latter  resulting 
almost  exclusively  from  later  refracture. 

In  direct,  and  especially  in  compound  fractures,  the  lower  fragment 
is  occasionally  divided  longitudinally  into  two  parts,  thus  giving  a  T-  or 
Y-fracture.  Comminution  is  a  frequent  result  of  direct  violence.  Longi- 
tudinal fracture  is  very  rare.  The  frequency  of  incomplete  fractures, 
namely,  fissures  not  involving  the  cartilage,  is  not  known  definitely,  as 
the  diagnosis  is  seldom  possible  without  the  .r-ray.  Fracture  of  the 
patella  usually  signifies  an  accompanying  injury  of  the  joint.    Associated 

Fig.  365. 


Recent  transverse  fracture  of  the  patella.     (▼.  Brans.) 

injuries  of  the  soft  parts  over  and  at  the  sides  of  the  patella  are  very 
significant.  The  fracture  may  be  purely  subaponeurotic  without  dis- 
placement or  typical  symptoms,  and  only  be  discovered  with  the  x-ray. 
Wegner  recently  reported  3  cases,  2  from  direct,  1  from  indirect  violence. 
In  the  greater  majority  of  cases  the  dense  fascia  covering  the  patella  is 
torn,  and  with  it  part  of  the  capsule,  the  reinforcing  tendinous  fibres  of 
the  vastus  interims  on  the  inner  side  and  the  prolongation  of  the  fascia 
lata  on  the  outer  side,  the  so-called  "reserve"  extensor  apparatus  of  the 
lea  is  thus  partially  or  completely  severed.  The  prepatellar  burst  is 
often  contused,  and  may  contain  blood  or  its  posterior  wall  may  be 
torn. 


FRACTURE  OF  THE  PATELLA.  575 

Macewen's  and  Konig's  clinical  observations  and  Holla's  experiments 
on  the  cadaver  have  shown  thai  the  tear  in  the  aponeurosis  does  nol 
always  correspond  to  the  fracture-line,  but  more  frequently  lies  above 
or  below  it,  the  tab  being  very  apt  to  get  between  the  fragments  and 
prevent  bony  union. 

Cause. — The  cause  is  usually  a  fall,  less  frequently  a  blow  from  a 
hoof  or  a  stone,  or  a  gunshot-wound,  etc.  All  compound  fractures  are 
unquestionably  direct.  Many  views  still  exist  at  the  present  time  as  to 
how  far  simple  transverse  fractures  are  referable  to  direct  or  indirect 
violence.  Many  patients  give  reliable  testimony  that  the  fracture  and 
the  pain  were  felt  at  the  moment  of  sudden  contraction  of  the  extensors 
to  prevent  a  fall  backward.  Sanson  affirmed  that  the  patella  was  bent 
while'  the  knee  was  flexed,  as  one  would  break  a  stick  over  the  knee. 
Bahr,  among  others,  demonstrated  later,  however,  that  in  the  flexed 
position  the  surface  of  the  patella  was  applied  closely  to  the  femur,  and 
that  the  contraction  of  the  quadriceps  merely  increased  the  contact. 
The  statistics  of  Bahr  and  Rossi  show  that  the  effect  of  muscular  traction 
has  been  overestimated,  Rossi  stating  that  the  infrequency  of  rupture 
of  the  quadriceps  tendon  or  the  ligamentum  patella?  pointed  rather  to 
a  pathological  condition  of  the  patella.  At  any  rate,  the  fracture  is 
commonly  the  result  of  a  direct  fall  upon  the  knee,  the  fracture  being  due 
to  the  fall  and  not  the  reverse.  The  view  that  in  falling  upon  the  knee 
the  blow  is  always  received  at  the  spine  of  the  tibia  and  not  upon  the 
patella  is  not  correct,  as  can  be  demonstrated  by  placing  the  hand 
under  the  knee;  it  applies  only  when  the  foot  is  extended.  When  the 
foot  is  flexed  the  lower  end  of  the  patella  strikes  the  ground,  and  the 
lower  portion,  projecting  beyond  the  condyles,  is  broken  off  transversely. 
When  the  patella  strikes  a  sharp  edge  it  may  be  broken  higher  up, 
transversely  or  obliquely. 

Symptoms. — The  patient  usually  hears  and  feels  the  snap  as  the  bone 
breaks  and  is  then  unable  to  extend  the  limb.  If  the  fracture  is  incom- 
plete or  purely  subaponeurotic,  and  the  lateral  portions  of  the  capsule 
are  intact,  the  patient  may  be  able  to  walk  or  even  to  climb  stairs.  The 
fragments  may  be  in  contact,  or  be  separated  by  a  slight  groove,  or  lie 
■j  to  I-  inch  apart  with  an  appreciable  transverse  groove  between  them. 
They  are  usually  separated  widely  if  there  is  very  much  hemorrhage 
into  the  joint.  The  fracture  may  be  concealed  by  hemorrhage  in  the 
prepatellar  bursa.  In  the  large  majority  of  cases  of  transverse  fracture 
the  displacement  is  marked.  As  a  rule,  the  .r-ray  is  necessary  to  diag- 
nose the  rare  incomplete  and  purely  subaponeurotic  fractures.  Crepitus 
is  absent  till  the  fragments  can  be  pressed  together.  Hemorrhage  into 
the  joint  is  constant  with  fracture  of  the  patella;  if  very  profuse,  it  may 
rupture  the  upper  recess  of  the  capsule,  as  noted  by  Riedel.  The  blood 
may  spread  out  beneath  the  quadriceps  and  under  the  skin  of  the  thigh. 

Prognosis. — Apart  from  the  age  of  the  patient  and  complications, 
especially  the  extent  of  the  tear  in  the  capsule,  the  prognosis  depends 
upon  the  treatment.  Simple  fracture  without  displacement  of  the  frag- 
ments is  usually  followed  by  bony  union  and  gradual  restoration  of 


576  INJURIES  OF  THE  KNEE. 

function.  The  greater  the  ateral  tear  of  the  capsule  and  of  the  reserve 
extensors,  the  greater  the  loss  of  active  extension ;  although  many  patients 
are  able  to  go  about  with  or  without  a  cane,  others  are  obliged  to  drag 
the  limb.  There  is  the  further  danger  of  partial  or  complete  stiffness. 
So  with  large  tears  of  the  capsule  the  prognosis  is  always  doubtful,  and 
is  at  least  less  favorable  than  the  prognosis  of  most  fractures  of  the 
shaft  of  the  bones. 

Treatment. — Non-union  or  inadequate  union  and  the  resulting  inability 
to  extend  the  leg  are  the  most  frequent  causes  of  partial  recovery.  That 
fibrous  union  and  the  absence  of  bony  union  are  not  due  to  insufficient 
nourishment  of  the  fragments  is  proved,  aside  from  the  cases  in  which 
bonv  union  occurs,  by  the  results  of  v.  Yolkmann's  transverse  division  of 
the  patella  in  resecting  the  joint.  The  fault  lies  in  improper  coapta- 
tion of  the  fragments,  and  this  in  turn  is  due  to  three  factors:  1.  Con- 
traction of  the  extensors.  2.  Intra-articular  hemorrhage.  3.  Interpo- 
sition of  periosteal  tabs,  as  cited  by  Maeewen,  Konig,  and  Hoffa.  The 
rational  treatment  therefore  consists  in  overcoming  these  three  hin- 
drances. 

Interposition  can  be  recognized  and  overcome  only  by  operation,  but 
as  it  is  present  in  only  a  part  of  the  cases  a  large  field  is  still  left  for 
conservative  treatment.  Hemorrhage  if  not  already  present  may  be 
prevented  somewhat  by  compression  with  wet  bandages  and  by  elevation 
in  a  Volkmann  splint  to  relax  the  extensors.  If  the  joint  is  much 
distended,  an  elastic  bandage  should  be  applied  or  the  joint  aspirated, 
as  done  by  Schede. 

The  coaptation  and  fixation  of  the  fragments  then  follow.  Only 
the  more  practical  methods  will  be  mentioned.  The  simplest  is  by 
means  of  an  adhesive-plaster  bandage,  the  upper  and  lower  transverse 
strips  being  applied  tightly  above  and  below  the  fragments  while  they 
are  held  in  position,  the  intervening  strips  exerting  uniform  pressure 
over  the  patella.  Rubber  plates  may  be  moulded  over  the  fragments 
to  give  a  better  hold.  The  plates  are  softened  in  hot  water,  applied, 
and  bandaged  in  place.  As  the  application  of  a  plaster-splint  is  liable 
to  be  followed  by  atrophy  of  the  quadriceps  and  stiffness  of  the  joint, 
it  is  better  to  use  a  long  strip  splint  and  massage  the  limb  daily,  v.  Bra- 
mann  obtains  continuous  elastic  pressure  against  the  fragments  by 
means  of  a  rubber  band  stretched  between  two  circular  adhesive  plaster 
strips,  applied  above  and  below  the  patella.  Bardenheuer  and  Lichten- 
auer  recommend  weight- extension,  the  same  as  for  fracture  of  the  femur, 
as  a  rule  after  aspirating  the  blood,  if  for  any  reason  open  suture  is  not 
possible  or  necessary.  Thirty  to  forty  pounds  are  applied  to  "tire  out" 
and  relax  the  extensors  and  thereby  overcome  the  traction  upon  the 
fragments;  the  extension  is  continued  for  four  to  six  weeks,  till  union 
occurs. 

Of  the  older  direct  methods,  Malgaigne's  clamp  method  is  merely  of 
historic  interest.  Trelat's  modification  of  this,  of  fastening  the  hooks 
to  rubber  plates  modelled  to  the  fragments,  has  no  advantage  over  the 
simple  bandage  described  above.     The  introduction  of  antisepsis  made 


FRA CT URE  OF  THE  I'M 'E L LA. 


577 


it  possible  to  suture  the  hones  with  less  apprehension;  that  the  ideal  is  not 
always  attained  by  suture,  however,  is  indicated  by  the  number  of  new 
met  hods  extant  and  the  constant  strife  over  subcutaneous  and  open  suture. 
Subcutaneous  suture  of  the  tendons,  proposed  by  v.Volkmann  in  1868, 
represents  the  forerunner  of  direct  suture  of  the  bone.  A  cord  was 
passed  transversely  through  the  ligamentum  patellae  and  another  through 
the  quadriceps  tendon  close  to  the  patella  and  the  ends  tied  together 
over  gauze.  Kocher  passed  a  silver  wire  on  a  curved  needle  underneath 
the  patella  from  above  and  out  below,  and  tied  the  ends  together  over  a 
gauze  pad;  at  first  he  made  two  short  incisions  through  the  skin  to  pre- 
vent necrosis;  later  he  made  a  long  incision  and  buried  the  suture. 
The  fixation  was  not  certain  and  the  wire  in  the  joint  irritated  the  carti- 
lage. Ceci  sutured  the  bone  subcutaneously  by  boring  through  the 
fragments  with  an  awl  having  an  eyelet:  beginning  at  the  lower  inner 
angle  he  bored  through  both  fragments  to  the  upper  outer  angle  of  the 
patella,  threaded  the  eye  with  silver 

wire    and  withdrew  it  ;    from  the  Fig.  3G6. 

lower  outer  angle  the  awl  was 
passed  along  the  lower  edge  of  the 
patella  to  the  first  hole  and  the 
wire  drawn  through  ;  from  the 
upper  inner  angle  the  awl  was 
passed  through  both  fragments  to 
the  last  hole,  threaded  and  with- 
drawn ;  the  two  ends  were  then 
united  through  the  quadriceps  ten- 
don at  the  upper  outer  angle, 
twisted  tightly,  cut  off,  and  inverted 
into  the  hole  into  the  bone  ;  the 
four  small  skin  punctures  healed 
quickly.  Heusner's  method,  simi- 
lar to  Butcher's  older  method,  of 
passing  the  silver  wrire  subcutane- 
ously around  the  patella  in  the 
tendons  and  periosteum,  differs 
from  Ceci's  method  in  thus  avoid- 
ing the  joint  and  in  encircling  the 
patella  rather  than  passing  in  a 
cross  through  it.  Barker  passed  a 
curved  awl  with  an  eyelet  into  the 
joint  below  the  patella  and  out 
above  the  upper  fragment,  threaded 
it  with  silver  wire  and  withdrew  it;  from  the  same  point  the  needle  was 
passed  subcutaneously  over  the  patella,  out  through  the  second  hole, 
threaded  with  the  other  end  of  the  wire,  withdrawn,  and  the  wire  tight- 
ened, twisted,  cut  off,  and  buried.  The  disadvantages  of  every  subcu- 
taneous method  are  that  the  interposition  of  the  periosteum  and  lateral 
tears  are  disregarded,  and  that  the  joint  may  be  opened. 
Vol.  Ill— 37 


Fracture  of  the  patella  united  by  suturing  the 
fragments,     (v.  Bruns.) 


578  INJURIES  OF  THE  KNEE. 

Open  suture  of  the  patella  under  antiseptic  conditions  was  first  per- 
formed by  Lister,  in  1878,  although  three  hundred  years  previously 
Severino,  and  later  Dieffenbach  and  Rhea  Barton,  had  performed  the 
same  operation.  Instead  of  Lister's  transverse  incision  at  the  level  of 
fracture,  a  longitudinal  incision  or  a  transverse  incision  not  in  line  with 
the  fracture  is  preferable.  The  blood  should  be  removed  from  the 
joint  as  fully  as  possible,  interposed  tissues  drawn  out  and  excised,  two 
or  three  holes  bored  through  the  fragments,  and  the  latter  drawn  together 
with  strong  silk,  catgut,  steel,  silver,  or  aluminum  bronze  wire,  and  the 
knots  or  twists  sunk  into  the  bone.  The  periosteum  and  fascia  are 
closed  by  continuous  or  interrupted  sutures.  The  skin  is  sutured  and  a 
splint  applied.     (Fig.  366.) 

Strict  asepsis  or  antisepsis  is  the  first  requisite  and  indispensable  con- 
dition; the  wound  should  be 'fingered  as  little  as  possible — in  fact,  it 
is  best  not  to  touch  the  wound  with  the  fingers  at  all,  but  to  make  the 
operation  completely  instrumental.  In  spite  of  primary  union  the 
results  are  not  always  satisfactory.  Fibrous  union  may  occur;  the 
function  may  be  impaired — that  is,  extension  and  flexion  are  limited. 
The  same  evil  consequences  as  produced  by  protracted  fixation  in  a 
plaster-splint  may  result,  namely,  shrinkage  of  the  capsule,  adhesions, 
atrophy  of  the  quadriceps.  Furthermore,  it  was  found  that  fibrous 
union  sometimes  produced  very  little  functional  impairment  in  spite  of 
a  diastasis  of  some  3  or  4  inches,  and  that  the  patient  was  fully  able  to 
work.  So  Lister's  operation  was  followed  later,  in  the  decade  of  1S90,  by 
the  development  of  the  treatment  by  early  massage  and  mobilization,  as 
recommended  by  Metzger,  Tilanus,  and  others.  This  is  in  fact  the 
application  of  the  modern  method  of  treating  joint  fractures  to  fracture 
of  the  patella.  Careful  massage  is  begun  twenty-four  to  forty-eight 
hours  after  the  injury,  the  joint  as  well  as  the  muscles  of  the  leg  and 
thigh  being  treated;  stroking  upward  aids  the  resorption  of  blood, 
tapotement  and  petrissage  strengthen  the  muscles.  The  fragments  are 
held  meanwhile  by  an  assistant.  The  faradic  current  may  be  beneficial. 
Gentle  passive  motion  is  begun  in  five  or  six  days;  in  twelve  to  fourteen 
days  the  patient  is  allowed  to  get  up  and  exercise,  walking  at  first  on 
crutches,  then  with  a  cane,  and  is  usually  discharged  in  six  weeks. 

Some  surgeons  (Kraske,  zum  Busch)  go  still  farther;  they  give  up  the 
idea  of  bony  union  from  the  outset,  allow  the  patient  to  go  about  on 
the  second  day,  walk  up  stairs  after  the  eighth  day,  and  report  good 
results,  zum  Busch  states  that  his  patients  were  able  to  go  about  on  the 
second  day  with  a  cane  without  crutches  and  were  all  able  to  work  in  four 
weeks;  they  could  flex  and  extend  the  leg,  walk  without  fatigue,  climb 
stairs,  and  do  the  hardest  exercises  at  the  latest  in  six  weeks,  namely, 
with  the  injured  limb  they  could  mount  a  chair  while  standing  close  to 
it.  Although  these  astonishing  results  show  the  great  importance  of 
massage  and  early  mobilization,  they  are  certainly  not  the  rule,  and  few 
surgeons  would  decide  to  follow  these  extreme  measures  of  zum  Busch. 
The  value  of  massage  is  unquestionably  overestimated;  it  is  chiefly 
useful  in  aiding  the  rapid  resorption  of  intra-articular  and  periarticular 


FRACTURE  OF  THE  PATELLA.  579 

as  well  as  intramuscular  hemorrhages,  and  indirectly  of  preventing  such 
hemorrhages  from  injuring  the  muscles,  namely,  by  causing  early  atrophy 
of  the  quadriceps.  Exercise  alone  can  preserve  and  increase  the  muscu- 
lar tone.  The  favorable  results  reported  by  zuin  Busch  are  therefore 
only  possible  with  relatively  slight  tears  of  the  capsule.  If  the  "reserve" 
extensors  are  torn  entirely  or  for  the  most  part,  the  functional  loss  leads 
inevitably  to  rapid  atrophy  of  the  extensors  in  spite  of  massage  and 
early  use  of  the  limb,  as  the  observations  of  Soutter  have  taught,  and 
the  contraction  of  the  muscles  has  the  disadvantage  of  increasing  the 
separation  of  the  fragments  and  the  difficulty  of  operative  union  later. 

To  the  author  it  seems  to  be  all  the  more  wrong  to  renounce  the  idea 
of  bony  union  from  the  onset,  because  refracture  occurs  with  distinctly 
greater  frequency  in  the  cases  of  fibrous  than  m  those  of  bony  union. 
Therefore  it  is  always  advisable  to  attempt  to  secure  exact  coaptation 
and  union  of  the  fragments  by  one  of  the  above  direct  methods,  but  at 
the  same  time  to  prevent  the  bad  results  of  protracted  immobilization 
and  disuse  by  instituting  massage  of  the  muscles  at  the  outset,  passive 
motion  early,  and  active  motion  after  about  the  twelfth  to  the  fourteenth 
day.  In  cases  with  little  tendency  to  separation  of  the  fragments  the 
joint  may  be  aspirated  and  a  splint  may  be  tried  first.  If  the  fragments 
cannot  be  approximated  after  removing  the  blood,  and  there  is  evidence 
of  a  tear  in  the  reserve  extensors  or  of  interposition  of  the  periosteum, 
open  suture  of  the  bones  is  indicated.  Trendelenburg  recommended 
not  to  undertake  operation  until  about  eight  days  after  the  injury,  in 
order  to  determine  meanwhile  the  chances  of  recovery  without  opera- 
tion, and  to  allow  the  swelling  of  the  soft  parts  to  subside  partially.  If 
open  suture  is  clearly  indicated,  there  is  nothing  to  prevent  its  being 
done  in  the  first  three  days  after  injury. 

Up  to  the  present  opinion  as  to  the  best  mode  of  treating  patellar 
fractures  has  shifted  from  one  point  of  view  to  another  and  has  not  yet 
become  uniform.  Whereas  up  to  about  eight  years  ago  there  was  a 
tendency  to  limit  more  and  more  the  indication  of  operation  in  favor  of 
massage  and  movements,  to-day,  in  view  of  the  perfection  of  aseptic 
technic,  the  tendency  is  to  do  away  with  subcutaneous  methods  and 
expose  and  suture  the  fragments.  One  important  advantage  of  suture 
over  bloodless  methods  is  that  motion  can  be  instituted  much  earlier 
without  fear  of  separation. 

In  compound  fractures  it  is  self-evident  that  the  patella  should  always 
be  sutured.  Suture  is  indicated  secondarily  if  bandaging  is  unsuccessful 
or  the  fracture  has  healed  with  weak,  extensile  fibrous  union.  On  account 
of  the  retraction  of  the  quadriceps  it  is  often  very  difficult  to  approximate 
the  fragments.  If,  with  the  muscles  fully  relaxed,  the  thigh  flexed,  and 
the  knee  extended,  the  fragments  cannot  be  approximated  with  silver  or 
silk  sutures,  the  ligamentum  patella3  or  the  quadriceps  may  be  divided, 
the  latter  by  V-shaped  or  lateral  incisions.  Porter  succeeded  in  approxi- 
mating the  fragments  in  two  old  cases  with  considerable  separation  by 
dividing  the  fascia  and  quadriceps  transversely  through  a  transverse 
incision  above  the  knee.   v.  Bergmann's  method  of  chiselling  off  the  spine 


580 


INJ  URIES  OF  THE  KNEE. 


of  the  tibia  is  better:  with  the  knee  flexed  an  incision  is  made  below  the 
spine  and  the  same  chiselled  off  obliquely  upward;  the  joint  is  not  opened. 
Even  then  it  may  be  impossible  to  approximate  the  fragments,  as  in  a  case 
of  Sonnenberg's.  Various  osteoplastic  methods  have  been  tried:  Rosen- 
berger  turned  down  a  flap  of  the  quadriceps  tendon  with  a  part  of  the 
upper  fragment,  turned  up  part  of  the  ligamentum  patella?  with  a  piece 
of  the  lower  fragment  and  sutured  the  two  tendinous  flaps  together.  Hel- 
ferich  placed  pieces  of  sterilized  bone  in  the  gap.  Wolff  bridged  over  the 
gap  with  bone-flaps  chiselled  from  the  upper  and  lower  fragments.  Tend- 

erich  advised  suture  of  the  cap- 

TT  QCV7  .  A 

sular  tear  alone  if  the  fragments 
could  not  be  approximated,  and 
cited  a  satisfactory  result  of  thus 
repairing  the  reserve  extensors. 

If  the  upper  fragment  becomes 
adherent  to  the  condyles  it  usually 
demands  excision.  Appropriate 
after-treatment  may  give  good 
results. 

If  all  measures  have  been  ex- 
hausted and  the  limb  is  still  dis- 
abled, an  apparatus  with  strong 
elastic  bands  replacing  the  action 
of  the  extensors  may  be  worn  per- 
manently. Resection  and  a  stiff 
joint  are  better  for  laborers  who 
are  compelled  to  carry  heavy 
weights  and  who  cannot  afford 
expensive  apparatus.  This  is  a 
last  resort,  but  a  stiff  joint  is  bet- 
ter than  a  limb  which  cannot  be 
extended. 

The  final  result  of  every  method 
often  does  not  differ  essentially 
from  the  conditions  at  the  close 
of  treatment.  Few  patients  re- 
cover the  full  use  of  the  limb;  ac- 
tive extension  is  seldom  complete, 
and  flexion  is  often  possible  only 
to  an  obtuse  or  right  angle.  Ac- 
tive flexion  and  extension  may  be 
increased  and  strengthened  dur- 
ing months  or  years  by  use,  or,  on  the  other  hand,  if  a  fibrous  union 
gives  gradually,  work  becomes  more  and  more  difficult  after  the  first 
year  and  is  finally  given  up.  In  Germany,  on  account  of  the  accident 
annuity,  it  is  often  difficult  to  determine  how  far  the  disability  is 
assumed  or  real.  If  actual,  the  thigh  muscles  are  found  to  be  atrophied, 
whereas  with  the  full  return  of  function  the  temporary  atrophy  dimin- 


Refracture  of  the  patella  three  months  after 
union  by  suture,  due  to  slipping  on  the  street. 
(Reichel.) 


RUPTURE  OF  THE  QUADRICEPS  TENDON.  $%\ 

ishes  and  the  thigh  regains  its  normal  size.  Refracture  occurs  relatively 
often;  it  is  most  common  within  the  first  few  weeks  of  resumed  activity, 
and  is  almost  always  in  the  callus.  (Fig.  367.)  Later  recurrence  may 
involve  the  callus  or  both  fragments,  and  may  be  in  the  form  of  a  tear- 
fracture,  or  be  due  to  direct  violence  like  the  original  break.  Rupture 
of  the  fibrous  union  may  cause  the  joint  to  be  opened,  as  noted  by 
Malgaigne.  The  treatment  is  the  same  as  that  of  the  former  injury; 
the  fracture  may  heal  by  bony  union.  If  dealing  with  a  second  rupture 
of  a  fibrous  union  and  separation  of  the  fragments,  it  is  better  to  freshen 
up  the  fragments  and  suture  them. 


RUPTURE  OF  THE  QUADRICEPS  TENDON  AND  THE  LIGA- 
MENTUM  PATELLA. 

Rupture  of  the  quadriceps  tendon  and  the  ligamentum  patella?, 
although  less  common  than  fracture  of  the  patella,  is  closely  related  to 
the  latter  etiologically,  as  is  easily  understood  from  the  fact  that  the 
patella  merely  represents  functionally  a  large  sesamoid  bone  interposed 
in  the  extensor  apparatus  of  the  leg.  The  mechanism  of  the  rupture 
is  not  quite  clear.  Usually  it  is  caused  by  forced  contraction  of  the 
quadriceps  to  prevent  falling;  the  tear  therefore  precedes  the  fall. 
Frequently,  however,  it  results  from  direct  trauma;  but  in  many  cases 
in  which  the  patient  falls  upon  the  knee  it  is  impossible  to  determine 
whether  the  fall  is  the  cause  or  the  result  of  the  rupture.  Occasionally 
no  cause  is  recognizable;  Maydl  reports  a  case  of  rupture  of  both 
quadriceps  tendons  while  the  patient  was  standing  still  upon  the  steps, 
Yulpius  a  case  in  which  the  tear  occurred  while  walking  quietly  on 
level  ground.  In  the  latter  instance  the  tendon  showed  marked  fatty 
degeneration.  In  another  case  of  Yulpius',  in  which  the  ligamentum 
patellae  was  torn  from  the  tibia,  there  was  a  sarcoma  of  the  head  of 
the  tibia. 

The  quadriceps  tendon  is  ruptured  somewhat  less  frequently  than 
the  ligamentum  patella?  and  usually  at  its  attachment  on  the  patella, 
often  with  avulsion  of  small  pieces  of  periosteum  or  bone.  Tears  at 
the  muscular  junction  are  less  common,  and  are  even  more  rare  in  the 
tendon  itself.  The  ligamentum  patellae  is  most  apt  to  tear  at  or  near 
its  attachment  on  the  tibia,  less  frequently  at  its  insertion  on  the  patella, 
very  seldom  in  the  middle.  Important  for  the  prognosis  and  treatment 
of  both  injuries  is  the  circumstance  that  the  piece  of  the  tendon  or 
ligament  attached  to  the  patella  is  liable  to  roll  under  between  the 
patella  and  the  femur  and  so  prevent  union  without  operative  inter- 
ference. 

At  the  moment  of  the  accident  the  patient  feels  an  intense  pain,  hears 
a  distinct  snap,  and  is  unable  to  walk.  Active  extension  is  lost  or 
incomplete.  If,  exceptionally,  the  tendon  alone  is  torn,  the  hemorrhage 
may  be  slight,  and  a  gap  i  to  f  inch  wide  can  be  seen  plainly  at  the 
point  of  rupture  between  the  stumps  of  the  tendon;  through  this  cleft 


582  INJURIES  OF  THE  KNEE. 

can  be  felt  the  articular  surface  of  the  femur.  As  the  tear  usually 
extends  more  or  less  into  the  reserve  extensors  and  the  capsule,  there 
is  profuse  hemorrhage  in  and  about  the  joint  and  swelling;  the  gap 
can  then  be  felt  but  not  seen. 

If  the  ligamentum  patella?  is  torn,  the  patella  is  displaced  from  h  to 
2  inches  upward,  a  symptom  which  could  only  be  mistaken  for  fracture 
of  the  patella,  which,  in  turn,  is  excluded  by  measuring  the  length  of 
both  patella?.  The  gap  can  be  felt  below  the  patella.  If  the  rupture 
is  at  the  lower  end  of  the  ligament,  the  capsule  may  be  uninjured;  if 
the  tear  is  higher  up,  the  capsule  is  also  torn  and  the  joint  fills  with 
blood.  Firm  fibrous  union  may  take  place  with  complete  restoration 
of  function  in  either  case,  but  frequently  active  extension  is  permanently 
impaired,  the  extensors  atrophy,  and  a  more  or  less  pronounced  limping 
gait  is  the  result. 

Treatment. — The  same  treatment  applies  as  in  the  case  of  fracture 
of  the  patella:  Elevation  of  the  limb  upon  a  splint  with  the  knee 
extended  and  the  hip  flexed,  removal  of  the  blood  by  compression  and 
massage  or  eventually  by  aspiration,  and  early  massage  of  the  muscles. 
Many  recommend  early  active  motion.  In  tears  of  the  ligamentum 
patella?  one  may  try  to  draw  down  the  patella  by  means  of  an  appropriate 
bandage,  as  in  the  case  of  fracture  of  that  bone.  If  asepsis  can  be 
assured,  it  is  better  to  incise  and  suture;  Blauel  reports  28  cases,  all 
resulting  favorably. 

Tear  Fracture  of  the  Spine  of  the  Tibia. — This  results  more 
often  from  a  direct  fall  upon  the  knee  than  from  muscular  action,  and 
is  most  common  in  adolescence.  It  may  be  a  pure  separation  in  the 
epiphyseal  line;  often,  however,  the  line  of  separation  lies  only  partly 
in  the  line  of  the  cartilage.  The  fragment  is  irregular  in  shape  and 
varies  in  size;  it  is  drawn  slightly  upward  by  the  quadriceps.  In  some 
of  the  cases  the  capsule  is  torn,  but  much  less  frequently  than  with 
rupture  of  the  ligament.  False  motion  and  crepitus  are  easily  demon- 
strated. 

Prognosis. — The  prognosis  is  favorable. 

Treatment. — The  treatment  consists  in  drawing  the  fragment  down 
to  its  normal  position  and  fixing  it  by  means  of  an  appropriate  bandage. 
The  limb  is  elevated  in  a  tin  or  wire  splint,  the  extensor  muscles  massaged 
early  and  long  immobilization  avoided.  Recovery  is  almost  always 
complete. 

DISLOCATIONS  OF  THE  KNEE. 

The  infrequency  of  dislocations  of  the  knee  is  due  to  the  strength  of 
the  ligaments.  They  are  produced  only  by  great  violence,  such  as  a 
fall  from  a  height,  descent  of  heavy  bodies,  railroad  accidents,  entangle- 
ment in  or  blows  from  machinery;  they  are  therefore  often  associated 
with  severe  injuries  elsewhere.  Fames  reports  forward  dislocation 
occurring  simultaneously  in  five  miners  who  dropped  170  feet  in  the 
elevator  of  a  mine-shaft.     The  author's  knowledge  of  the  mechanism 


DISLOCATIONS  OF  THE  KNEE. 


583 


of  origin  is  derived  less  from  clinical  observations  than  from  experiments 
on  the  cadaver.  The  dislocation  may  be  complete  or  incomplete,  forward 
or  backward,  outward  or  inward.  Forward  and  backward  it  is  more 
often  complete;  laterally,  incomplete. 

Dislocation  Forward. — Forward  dislocation  is  the  most  common 
form.  (Fig.  368.)  The  cause,  actually  and  experimentally,  is  forcible 
hyperextension,  less  frequently  a  blow  upon  the  lower  end  of  the  femur 
from  in  front  with  the  leg  fixed. 


Fig.  368 

* 

\      \  1 

'%      \  \ 

i, 

Forward  dislocation  of  the  leg.     (v.  Bruns.) 


Symptoms. — The  extensors  and  anterior  portion  of  the  capsule  remain 
intact,  the  posterior  portion,  both  crucial  ligaments,  and  the  greater 
part  of  one  or  both  of  the  lateral  ligaments  at  their  points  of  attachment 
are  torn.  The  condyles  slide  back  on  the  tibia  and  their  contour  can  be 
seen  and  felt  in  the  popliteal  space;  the  patella  lies  in  the  angle  between 
the  condyles  and  the  condylar  surfaces  of  the  tibia;  the  joint  is  slightly 
flexed.  The  skin  in  front  of  the  joint  is  thrown  into  folds;  the  limb  is 
shortened,  the  anteroposterior  diameter  of  the  knee  increased. 

Treatment. — Reduction  in  recent  cases  is  generally  easy  by  careful 
hyperextension,  traction,  and  direct  pressure. 

Dislocation  Backward. — Backward  dislocation  can  be  produced  on 
the   cadaver  only  by  placing  a  thick  wooden  wedge   in  the  popliteal 


584 


INJURIES  OF  THE  KNEE. 


space  and  hyperflexing.  (Figs.  369  and  370.)  It  is  usually  caused  by  a 
blow  from  in  front  upon  the  leg  while  flexed.  It  is  as  often  complete  as 
incomplete. 

Symptoms. — The  soft  parts  behind  are  stretched  tightly  over  the  head 
of  the  tibia  and  may  be  torn.  The  patella  lies  almost  horizontally 
under  the  trochlea.  The  leg  is  slightly  hyperextended.  The  antero- 
posterior diameter  of  the  joint  is  increased.  Its  configuration  is  so 
characteristic  that  a  mistake  is  hardly  possible.  The  functional  loss  is 
absolute,  although  cases  are  known  in  which  walking  was  possible  later 
in  spite  of  non-reduction. 

Treatment. — Reduction  consists  in  flexion  to  a  right  angle,  direct 
pressure  forward,  and  then  extension  with  traction  in  the  long  axis  of 
the  leg. 

Lateral  Dislocations. — Lateral  dislocations  are  more  often  incom- 
plete than  complete,  in  outward  dislocation  the  outer  condyle  lying  upon 


Fig.  369. 


Fig.  370. 


Complete  backward  dislocation  of  the  leg.     (Hoffa.) 

the  inner  condylar  surface  of  the  tibia  and  the  reverse  in  inward  dislo- 
cation. At  the  same  time  the  leg  is  often  displaced  forward  or  backward 
or  rotated.  In  outward  dislocation  the  internal  lateral  ligament  is  torn, 
in  inward  dislocation  the  external  lateral  ligament,  the  tear  in  the 
capsule  always  extending  above  it;  if  the  dislocation  is  complete,  the 
crucial  ligaments  are  always  ruptured;  if  incomplete,  they  are  usually 
ruptured  or  badly  torn.  Instead  of  the  lateral  ligament  tearing,  the 
epicondyle  or  pieces  of  the  condyle  may  be  pulled  off.  In  the  cadaver 
lateral  dislocations  may  be  produced,  after  dividing  the  corresponding 
lateral  ligament,  by  abducting  or  adducting  the  leg  forcibly. 

Symptoms. — In  the  rare  complete  lateral  dislocations  the  head  of  the 
tibia  lies  to  the  inner  or  outer  side  of  the  femur,  the  transverse  diameter 
of  the  joint  being  doubled;  the  joint-surfaces  can  be  felt  easily  through 


DISLOCATIONS  OF  THE  KNEE. 


585 


the  stretched  or  torn  soft  parts;  the  limb  is  shortened;  the  leg  may 
depend  loosely,  and  be  capable  of  being  Hexed  and  hyperextended 
passively;  it  is  rotated  either  inward  or  outward.  In  the  more  frequent 
incomplete  dislocation  the  stability  of  the  joint  is  not  entirely  lost;  the 
deformity  and  broadening  are  less  marked,  and  are  always  masked  by 
the  verv  large  effusion  of  blood  in  and  about  the  joint;  the  limb  is  not 
shortened,  but  the  leg  is  abducted  or  adducted  more  than  in  the  complete 
form. 

Diagnosis. — That  the  diagnosis  may  be  difficult  is  shown  by  a  case  of 
Bahr's,  in  which  after  reduction  in  the  ordinary  way  the  knee  could 
be  flexed  fully  but  remained  stiff  on  being  extended;  the  a>ray  showed 
that  the  original  inward  dislocation  had  been  changed  to  an  incomplete 
outward  dislocation  by  the  reduction,  the  external  condyle  being  caught 
in  front  of  the  outer  tubercle  of  the  spinous  process. 


Fig.  371. 


COlMj- 


Roberts'  case  of  dislocation  of  the  knee  outward  with  abduction.     (Stimson.) 


Treatment. — Reduction  is  usually  easy  by  traction — if  necessary  with 
accentuation  of  the  existing  adduction  or  abduction — and  return  to  the 
normal  position  with  appropriate  pressure  upon  the  joint.  If  left  unre- 
duced, walking  may  still  be  possible,  but  the  abduction  or  adduction 
usually  increases. 

Rotation  of  the  tibia  is  very  rare.  Wille  could  only  collect  13  cases, 
of  which  4  were  complete,  all  outward,  and  9  incomplete,  some  of  these 
inward,  some  outward.  They  were  usually  combined  with  subluxation 
in  some  other  direction. 

Complications. — The  chief  danger  of  all  dislocations  of  the  knee  lies 
in  the  accompanying  laceration  of  the  soft  parts.  These  are  stretched 
to  the  utmost  by  reason  of  the  size  of  the  dislocated  articular  ends, 
and  not  infrequently  tear  at  the  moment  of  injury  or  during  reduction 
or  later  become  necrotic  from  the  pressure  of  the  edges  of  the  bones. 
Thus  a  simple  dislocation  can  become  compound  secondarily.  Lacera- 
tion of  the  large  vessels  is  even  more  serious;  it  may  occur  while  the 
skin  remains  intact. 


586  INJURIES  OF  THE  KNEE. 

Lefiltiatre  reports  a  case  of  backward  and  outward  dislocation  pro- 
duced by  suspension,  the  foot  being  caught  between  the  palings  of  a 
fence;  all  the  ligaments  were  ruptured,  the  thigh  being  held  only  by  the 
skin  and  a  few  muscles. 

One  or  both  popliteal  vessels  may  be  lacerated,  or  the  intima  alone 
may  be  torn  and  thrombosis  follow.  Such  lesions  are  particularly  apt 
to  occur  in  backward  dislocation  from  the  pressure  of  the  sharp  edge 
of  the  head  of  the  tibia.  Rupture  of  the  nerves  is  rare;  more  often  the 
function  of  the  tibial  and  peroneal  nerves  is  arrested  by  severe  contusion. 
Laceration  of  both  popliteal  vessels  is  always  followed  by  gangrene  of 
the  leg,  and  requires  amputation.  Rupture  or  thrombosis  of  the  artery 
alone  is  usually  equally  disastrous,  as  the  contusion  of  the  surrounding 
soft  parts,  which  goes  with  it,  prevents  the  timely  development  of  the 
collateral  circulation.  At  first  only  a  probable  diagnosis  may  be  possible 
in  simple  dislocation  from  the  condition  of  the  pulse  in  the  distal  arteries, 
for  it  is  at  this  time  that  the  symptoms  of  a  traumatic  aneurism,  a 
tumor  growing  rapidly  in  the  popliteal  space,  develop  very  quickly. 
A  severe  lesion  of  the  artery  is  practically  excluded  by  distinct  pulsation 
of  the  posterior  tibial  behind  the  internal  malleolus.  Pulselessness  should 
always  arouse  suspicion  of  partial  laceration  or  thrombosis.  The  con- 
dition of  the  circulation  of  the  foot  and  leg  should  be  watched  carefully 
for  some  time  even  after  reduction. 

In  the  event  of  any  of  the  above  complications  the  prognosis  for  the 
first  few  days  is  doubtful  or  even  serious;  otherwise  it  is  not  unfavorable. 
Although  some  stiffness  may  persist  for  a  time,  full  use  of  the  limb 
usually  returns  in  from  one  to  three  years.  In  the  first  few  months  one 
should  watch  for  popliteal  aneurism. 

Treatment. — If  the  skin  is  intact,  it  should  not  be  injured  in  the 
reduction.  After  reduction  the  limb  is  enveloped  in  cotton  and  bandaged 
with  moderate  pressure,  and  laid  and  elevated  in  a  long  well-padded 
wire-  or  tin-splint.  As  there  is  little  tendency  to  displacement,  a  plaster 
splint  is  not  necessary,  and  is  counterindicated  by  the  swelling.  In  the 
absence  of  any  circulatory  disturbance  regular  massage  of  the  knee  and 
thigh  is  begun  in  three  or  four  days,  but  not  till  the  end  of  the  second  or 
third  week  if  there  is  any  suspicion  of  thrombosis  of  the  popliteal  vein; 
in  the  latter  case  massage  should  be  limited  to  the  parts  at  a  distance 
from  the  vein  to  avoid  loosening  the  thrombus.  Mobilization  of  the 
joint  is  begun  in  the  third  week.  If  up,  the  patient  should  use  crutches 
and  wear  a  removable  plaster-  or  silicate-splint;  later  a  sheath  splint 
hinged  at  the  knee.  Compound  dislocations  require  the  same  strict 
treatment  applied  to  compound  fractures.  Amputation  is  indicated  if 
the  popliteal  vessels  or  simultaneously  the  sciatic  or  tibial  nerves  are 
ruptured  or  the  muscles  badly  torn. 

Reduction  is  rendered  easy  in  the  majority  of  cases  by  the  usually 
extensive  laceration  of  the  ligaments.  It  may  be  prevented,  however, 
even  under  anaesthesia,  by  the  tension  of  the  soft  parts,  especially  the 
extensors,  or  by  interposition  of  portions  of  the  capsule  or  by  dislocated 
menisci;  operation  is  then  necessary,  and  has  the  advantage  of  allowing 


DISLiK-ATlnSs  OF  THE  KSEE. 


587 


the  blood  to  be  removed  from  the  joint.  If  one  is  certain  of  his  asepsis, 
the  incision  may  be  closed;  otherwise  it  is  better  to  insert  two  lateral 
drainage-tubes. 

Habitual  Subluxation  of  the  Knee. — In  conclusion  should  be  men- 
tioned a  rare  affection  resulting  from  a  relaxed  condition  of  the  capsule. 
Robinson  reports  3  cases  of  this  sort  in  female  infants  under  twelve 
months,  whose  general  condition  was  poor.  There  was  abnormal  lat- 
eral mobility  of  the  joint  permitting  of  sudden  outward  displacement 
and  rotation  of  the  tibia;  this  occurred  with  a  snap,  and  was  reduced 
with  equal  rapidity  on  active  motion.  Recovery  was  effected  by  massage 
and  by  strengthening  the  general  condition.  Lissauer  reports  a  case  of 
voluntary  dislocation  following  traumatic  dislocation  and  reduction  on 
the  fifth  day. 

Fig.  372. 


Congenital  dislocation  of  the  knee.     (Stimson.) 


Congenital  Forward  Dislocation. — This  is  not  an  actual  dislocation, 
but  a  congenital  genu  recurvatum,  an  abnormal  hyperextension  of  the 
knee,  as  stated  by  Phokas,  who  collected  23  cases  in  1891.  The  accom- 
panying illustration  (Fig.  372)  is  an  observation  of  Stimson's,  and  shows 
the  characteristic  attitude  of  the  limb.  The  condyles  project  slightly 
backward,  the  skin  in  front  shows  several  transverse  folds.  The  patella 
is  small  but  always  present.  Flexion  actively  is  impossible,  passively 
possible  only  to  an  obtuse  angle,  the  leg  springing  back  to  the  abnormal 
position  if  released.  The  dislocation  is  usually  unilateral,  very  excep- 
tionally bilateral.  The  etiology  and  pathogenesis  are  not  known  posi- 
tively. 

Treatment. — The  only  treatment  is  to  gradually  flex  the  leg  in 
plaster-splints  until  the  normal  position  is  attained  and  can  be 
retained. 


588 


INJURIES  OF  THE  KNEE. 


DISLOCATION  OF  THE  PATELLA. 

Dislocation  of  the  patella  is  really  a  displacement  of  the  quadriceps 
tendon,  although  the  former  term  is  still  retained.  Surgeons  distinguish: 
1.  Lateral  dislocation.  2.  Rotation  about  its  long  axis.  3.  Dislocation 
downward  in  the  cleft  between  the  femur  and  tibia. 

Lateral  Dislocation. — This  form  is  most  common,  and  is  almost 
always  outward.  (Figs.  373  and  374.)  Malgaigne  reports  one  case  of  com- 
plete dislocation  inward.  The  dislocation  outward  is  incomplete  or  com- 
plete according  as  the  patella  is  still  in  contact  with  the  joint-surface  or 


Fig.  373. 


Fig.  374. 


Complete  dislocation  of  the  patella  outward.     (Hoffa.) 

lies  upon  the  epicondyle.  Both  forms  occur  with  about  equal  frequency. 
The  rarity  of  inward  dislocation  is  attributed  to  the  size  and  more 
rounded  form  of  the  inner  condyle,  the  greater  prominence  of  the  inner 
edge  of  the  patella,  and  therefore  greater  exposure  to  violence,  and 
finally  the  slight  physiological  inward  curvature  of  the  limb  as  the  result 
of  which  the  extensor  apparatus  is  too  short  normally  to  be  displaceable 
over  the  inner  condyle.  Experimentally  Streubel  was  unable  to  dislocate 
the  patella  inward,  while  it  could  be  easily  pushed  outward  with  a 
carpenter's  clamp. 

A  blow  or  fall  upon  the  inner  edge  of  the  patella  is  the  usual  cause 
of  outward  dislocation.  In  Malgaigne's  case,  a  cavalryman,  the  patella 
was  struck  by  his  opponent  in  riding  by.    A  sudden  forcible  contraction 


CD 

a 

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DISLOCATION  OF  THE  PATELLA.  539 

of  the  quadriceps  is  apparently  more  frequently  the  cause,  especially  if 
the  knee  is  flexed  and  turned  inward,  as  in  wrestling  or  in  falling.  Genu 
valgum  increases  the  predisposition.  The  hone  is  also  displaced  upward 
or  downward  slightly  according  to  the  nature  of  the  force  and  the  position 
of  the  knee  in  extension  or  flexion.  The  capsule  is  torn  longitudinally 
along  the  inner  side  to  an  extent  varying  according  to  the  completeness 
of  the  dislocation.  In  complete  dislocation  it  may  be  torn  the  whole 
length  of  the  anterior  wall.  The  outer  part  of  the  capsule  is  thrown 
into  folds,  which  can  be  felt  at  the  side  of  the  quadriceps  tendon;  the 
inner  margin  of  the  tear  and  the  quadriceps  tendon  are  visibly  and 
palpably  tense.  The  knee  is  bent  inward  and  flexed  slightly,  and  the 
ieg  rotated  outward;  the  patella  forms  a  distinct  projection  at  the  outer 
side  of  the  joint;  the  trochlea  is  empty  and  can  be  palpated.  If  the 
dislocation  is  incomplete,  all  these  symptoms  are  less  pronounced. 

Prognosis. — The  prognosis  is  usually  favorable.  Even  if  the  disloca- 
tion persists  the  use  of  the  limb  is  gradually  recovered,  and  hard  labor 
is  possible,  but  extension  is  limited  and  the  genu  valgum  becomes  more 
pronounced.  Full  recovery  may  follow  early  reduction.  If  used  too 
soon,  or  if  a  serous  effusion  stretches  the  capsule,  or  the  patient  had  a 
genu  valgum  before  the  accident,  the  dislocation  may  become  habitual. 
Aldibert  regards  genu  valgum  as  the  most  frequent  cause  of  the  dislo- 
cation. Chronic  synovitis  and  weakness  of  the  knee  usually  develop 
gradually  and  compromise  the  working  ability  of  the  patient. 

Treatment. — In  recent  eases  reduction  usually  is  easy,  at  least  under 
anaesthesia,  by  flexing  the  thigh,  extending  the  knee,  and  exerting  direct 
pressure.  Moderate  compression  is  applied  and  the  limb  immobilized 
in  a  gutter  splint;  massage  of  the  knee  and  quadriceps  is  begun  after 
the  third  or  fourth  day,  passive  motion  after  five  or  six  days,  active 
motion  in  ten  to  fourteen  days.  An  elastic  knee-cap  is  worn  for  several 
weeks. 

Repeated  dislocation  requires  longer  immobilization,  three  to  four 
weeks  in  a  plaster-splint;  habitual  dislocation  requires  operation. 
Bandages  if  worn  long  are  annoying  and  in  severe  cases  are  uncertain. 
Operation  has  given  good  results.  If  the  capsule  is  relaxed  on  the  inner 
side,  a  slightly  curved  longitudinal  incision  is  made  at  the  inner  side 
of  the  patella,  and  an  oval  piece  cut  out  of  the  capsule  (Bajardi),  or  it 
is  reefed  (Bereaux,  Le  Dentu)  the  same  as  in  Ricard's  operation  for 
habitual  dislocation  of  the  shoulder.  If  the  cause  is  traction  of  the 
extensors  in  an  improper  direction,  the  spine  of  the  tibia  may  be 
chiselled  off,  shifted  to  the  inner  side,  and  nailed.  If  genu  valgum  is 
the  chief  cause,  it  would  indicate  osteotomy  or  orthopaedic  treatment. 

Congenital  Dislocation  of  the  Patella. — The  rare  congenital  dislocation 
is  treated  the  same  as  habitual  dislocation  if  it  produces  disturbance. 
Bessel-Hagen  distinguishes  three  forms:  1.  Incomplete — the  patella  lies 
on  the  external  condyle  but  slips  into  the  trochlea  in  flexion.  2.  Complete 
intermitting — the  dislocation  takes  place  in  flexion  but  reduces  in  exten- 
sion. 3.  Complete  continuous — the  patella,  displaced  outward,  is  dis- 
placed further  in  flexion.     Secondary  changes  develop  in  the  ligaments, 


590  INJURIES  OF  THE  KNEE. 

muscles,  and  bone.  The  external  condyle  becomes  flattened  and  the 
corresponding  half  of  the  trochlea  smaller  or  obliterated.  (Appel.) 
Bessel-Hagen's  3  cases  occurring  in  sisters  would  point  more  perhaps  to 
faulty  embryonal  construction  than  to  mechanical  influences  in  utero. 
The  dislocation  may  produce  no  functional  disturbance  for  a  long  time; 
Schon  saw  a  thirteen-year-old  girl  whose  gait  was  at  first  unimpaired, 
but  in  whom  gradually  a  pronounced  genu  valgum  and  habitual  dislo- 
cation developed.  Menard  saw  an  eight-year-old  boy  whose  left  patella 
was  rotated  outward,  and  stood  edgewise  when  the  knee  was  flexed  to  a 
right  angle;  flexion  further  was  impossible. 

Treatment. — The  treatment  is  the  same  as  that  of  habitual  disloca- 
tion if  the  patella  is  troublesome.  To  prevent  secondary  disturbances, 
the  patella  should  be  secured  in  its  normal  position  either  by  orthopaedic 
measures  or  by  operation  at  about  the  fourth  year. 

Vertical  Dislocation  of  the  Patella. — In  this  much  rarer  form  the 
patella  is  always  displaced  laterally  more  or  less  and  then  rotated  about 
its  long  axis  until  it  stands  edgewise  in  the  trochlea.  Lateral  displace- 
ment is  always  accompanied  by  a  certain  degree  of  rotation,  so  that  in 
every  incomplete  outward  dislocation  the  outer  edge  of  the  patella  is 
rotated  forward.  If  this  rotation  is  increased  the  other  edge  becomes 
caught  in  the  trochlea,  in  outward  dislocation  the  inner  edge,  in  inward 
dislocation  the  outer  edge,  and  the  cartilaginous  surface  faces  corre- 
spondingly outward  or  inward.  This  occurs  inward  or  outward 
with  about  equal  frequency.  Exceptionally  the  rotation  continues 
until  the  patella  is  completely  reversed,  the  periosteal  surface  against 
the  trochlea,  the  cartilage  facing  forward.  Parker  and  Borchard  each 
describe  a  case  of  complete  outward  dislocation  of  the  patella  with 
simultaneous  outward  vertical  dislocation. 

The  same  causes  are  active  as  in  lateral  dislocation;  a  direct  fall 
upon  the  knee  with  the  limb  strongly  abducted  (Vergaly);  a  blow  upon 
the  outer  side  of  the  knee  (inward  vertical  dislocation,  Link);  sudden 
contraction  of  the  quadriceps  (Anderson);  sudden  rotation  of  the 
body  about  the  long  axis  of  the  leg  while  standing  (Gohlich).  The 
patella  is  held  in  the  vertical  position,  as  shown  by  Streubel,  by  the 
tension  of  the  folded  and  intact  capsule  on  the  side  opposite  to  that 
toward  which  the  cartilaginous  surface  is  directed.  Wolff's  attempts  at 
reduction  by  dividing  the  quadriceps  tendon  and  ligamentum  patellae 
subcutaneously  were  thus  illogical  and  futile.  The  dislocation  also  pre- 
supposes an  extensive  longitudinal  tear  of  the  capsule  on  the  opposite 
side;  if  complete,  on  both  sides  of  the  patella.  In  a  case  of  Voigt's 
the  patellar  ligament  was  torn  completely,  the  quadriceps  tendon 
partially. 

Symptoms. — The  knee  is  extended,  the  rotated  patella  projects  forward; 
the  quadriceps  tendon,  ligamentum  patellae,  and  margin  of  the  capsular 
tear  are  stretched  tightly.  In  Gohlich' s  case  the  foot  was  in  a  pro- 
nounced varus  position.  It  is  often  difficult  and  equally  important  to 
determine  which  way  the  patella  has  rotated;  the  cartilaginous  surface 
is  recognized  by  the  vertical  ridge. 


DISLOCATION  OF  THE  MEM  SCI.  591 

Treatment. — Reduction  in  many  cases  is  very  easy  by  relaxing  the 
extensors,  namely,  flexing  the  hip  and  hyperextending  the  knee,  and  by 
manipulating  the  patella.  In  others  it  is  difficult  even  under  anaesthesia. 
It  is  a  good  plan  to  place  the  leg  on  one's  shoulder.  In  difficult  cases 
a  hammer  or  carpenter's  clamp  has  been  used,  but  longitudinal  incis 
ion  and  the  use  of  an  elevator  or  hook  are  better;  some  force  may  be 
required,  or  it  may  be  necessary  to  divide  the  tense  parts  of  the  capsule. 
If  the  patella  is  completely  reversed,  operation  may  be  necessary  for 
diagnosis  as  well  as  reduction.  If  the  patella  cannot  be  turned  over,  it 
is  excised.  Recovery  is  often  rapid;  Link's  patient  was  up  in  five 
days  and  discharged  cured  in  ten  days.  Prudence  demands  somewhat 
longer  treatment.  Recovery  may  be  delayed  by  chronic  serous  syno- 
vitis due  to  intra-articular  effusion  of  blood. 

Dislocation  Downward  of  the  Patella.— This  term  has  been  recently 
applied  to  a  so-called  third  form  of  dislocation,  namely,  downward  with 
wedging  of  the  patella  between  the  femur  and  tibia.  Only  4  cases 
could  be  found  in  the  literature.  The  characteristic  one  was  observed 
by  Szuman;  the  extensors  were  intact.  The  patient  had  fallen  under 
the  iron  oscillator  of  a  chaff-cutter  and  had  received  several  blows 
about  the  left  knee:  the  quadriceps  tendon  was  dislocated  outward 
and  the  ligamentum  patellae  was  partly  twisted,  but  both  were  intact; 
the  crucial  and  outer  lateral  ligaments  were  ruptured.  The  patella 
was  wedged  between  the  femur  and  tibia  with  its  joint-surface  facing 
upward.  Reduction  necessitated  division  of  the  ligamentum  patella?. 
The  final  result  was  satisfactory.  In  the  3  other  cases  cited  by  Midel- 
fart,  Deaderik,  and  E.  Schmidt,  the  quadriceps  tendon  was  ruptured 
at  the  patella,  in  the  first  case  by  falling  upon  a  sharp  stone,  in  the 
second  by  jumping  on  a  moving  train,  in  the  third  by  slipping  and  falling 
upon  a  railroad  track.  In  all  3  cases  the  patella  was  rotated  on  its 
transverse  axis,  wedged  in  the  cleft  of  the  joint,  and  prevented  passive 
extension.     Operation  was  successful  in  all. 


DISLOCATION  OF  THE  MENISCI. 

Our  knowledge  of  this  not  infrequent  but  previously  unrecognized  or 
disregarded  injury  has  been  greatly  clarified  and  extended  by  v.  Bruns' 
article,  published  in  1S92.  After  being  contented  for  a  long  time  with 
the  diagnosis  of  a  "derangement  interne,"  dislocation  of  the  menisci 
has  become  the  subject  of  numerous  investigations,  so  that  the  literature 
is  now  quite  extensive.  The  lesion  consists  in  a  partial  avulsion  of  one 
or  both  of  the  semilunar  cartilages,  either  in  front  of  or  behind  the 
spinous  process,  or  somewhere  along  the  attachment  to  the  capsule  or  to 
the  cartilaginous  surface  of  the  tibia.  Exceptionally  the  meniscus  is 
torn  at  its  base  from  the  capsule  and  forced  into  the  joint,  the  anterior 
and  posterior  ends  remaining  attached.  It  is  frequently  divided  into  two 
or  three  pieces  in  a  transverse  or  longitudinal  direction.  The  internal 
meniscus  is  affected  more  than  twice  as  often  as  the  external,    (v.  Bruns.) 


592  INJURIES  OF  THE  KNEE. 

Symptoms. — The  cartilage  may  not  be  displaced,  and  may  unite 
again  with  sufficient  rest;  but  very  often  it  is  displaced  forward,  back- 
ward, outward,  or  inward,  becomes  wedged  between  the  joint-surfaces, 
and  produces  pain  and  impairment  of  function,  and  by  the  continual 
irritation  inflammation  of  the  synovialis  and  serous  effusion.  The 
lesion  is  usually  due  to  some  rather  slight  external  cause,  commonly  a 
sudden  forced  rotary  movement  of  the  knee  while  the  same  is  flexed. 
It  occurs  chiefly  in  young  and  muscular  men.  The  inner  meniscus  is 
displaced  by  outward  rotation  of  the  leg  with  the  knee  flexed  slightly 
or  at  a  right  angle,  the  outer  by  inward  rotation,     (v.  Brims.) 

At  the  moment  of  the  accident  the  patient  feels  an  intense  pain  at  the 
point  of  injury,  which  may  be  sufficiently  severe  to  produce  momentary 
syncope,  after  which  the  movement  of  the  knee  is  impaired.  There 
may  be  a  slight  intra-articular  effusion  of  blood  and  moderate  swelling. 
If  the  cartilage  is  merely  torn  and  not  displaced,  or  is  displaced  inward, 
nothing  abnormal  can  be  felt,  but  palpation  is  painful  at  the  point  of 
injury.  If  displaced  forward  or  laterally,  the  cartilage  may  be  felt 
projecting  more  or  less  distinctly. 

The  effusion  is  absorbed  rather  rapidly  and  the  symptoms  subside  in 
a  few  days,  with  rest,  hot  compresses,  and  massage.  A  certain  amount 
of  weakness,  tenderness,  and  inability  to  extend  or — if  the  outer  meniscus 
is  displaced — to  flex  the  knee  are  left.  The  pain  is  increased  by  certain 
movements;  frequently  there  is  a  slight  synovitis.  If  the  injury  is  not 
recognized,  the  patient  may  be  disabled  for  years  and  be  treated  alter- 
nately with  rest,  plaster-splints  or  massage,  medico-mechanical  meas- 
ures, or  hydrotherapy,  till  the  proper  diagnosis  is  finally  made  and  the 
condition  improved  by  operation.  The  patient  sometimes  calls  the 
attention  of  the  surgeon  to  a  certain  spot  where  the  dislocated  cartilage 
can  be  felt  and  moved,  or  the  condition  may  be  recognized  only  on 
careful  palpation,  or  be  surmised  from  the  history  and  be  established 
only  by  operating.  In  addition  to  traumatic  avulsion  of  the  semilunar 
cartilage,  Allingham  distinguishes  a  gradual  loosening  produced  by  the 
stretching  of  the  capsule  due  to  inflammatory  processes.  Such  an 
etiology  is  not  established  positively,  for  trauma  has  usually  preceded 
the  condition,  even  years  before,  and  the  oft-seen  inflammatory  effusion 
in  the  joint  is  not  to  be  regarded  as  the  cause,  but  rather  as  the  result  of 
the  dislocation  of  the  cartilage. 

Treatment. — If  recognized  early,  after  reducing  the  cartilage  the  joint 
should  be  immobilized  long  enough  to  permit  union.  Reduction  is  only 
possible  if  the  fragment  is  displaced  toward  the  surface:  The  limb  is 
placed  in  the  position  in  which  dislocation  occurred,  namely,  in  the  case 
of  the  inner  meniscus,  by  flexing  and  rotating  the  leg  outward;  while 
exerting  constant  pressure  upon  the  projecting  cartilage  with  one  hand 
the  leg  is  rotated  strongly  inward  and  extended  quickly.  The  opposite 
procedure  is  performed  in  the  case  of  the  outer  meniscus,  namely, 
flexion  and  inward  rotation;  the  limb  is  then  immobilized  upon  a 
padded  tin-splint  or  in  plaster;  later  massage  and  passive  motion;  at 
the  end  of  five  to  six  weeks  the  patient  is  allowed  to  walk,  avoiding  the 


DISLOCATION  OF  THE  ME  SI  SCI.  593 

movements  favoring  dislocation — that  is,  walking  with  the  foot  turned 
outward  if  the  outer  meniscus  was  injured,  and  the  reverse  for  injury 
of  the  inner  meniscus. 

If  the  dislocation  cannot  be  reduced  or  has  existed  for  weeks, 
months,  or  years,  operation  is  indicated:  a  curved  longitudinal 
incision  is  made  at  the  point  of  injury  or  transversely  at  the  level 
of  the  joint,  extending  3  inches  backward  from  the  margin  of  the  pa- 
tella (Vollbrecht) ;  the  joint  is  opened,  the  displaced  cartilage  is  drawn 
out  with  a  small  blunt  hook  and  sutured  in  place  with  catgut  if  in 
good  condition  ( Allingham),  or  else  removed.  An  entire  meniscus  has 
been  removed  without  impairment,  (v.  Bruns.)  If  sure  of  one's  asepsis 
the  joint  is  closed;  otherwise — and  this  is  rarely  necessary  at  the  present 
time — a  drainage-tube  is  left  in  for  a  few  days. 

Both  methods  give  good  results  if  primary  union  is  obtained.  The 
excision  of  the  meniscus  is  usually  without  functional  loss.  Patients 
who  have  suffered  for  years  regain  complete  flexion  and  extension  and 
the  full  use  of  the  limb.  To  be  sure,  the  result  is  not  always  so  favorable; 
Nissen  reports  a  case  in  which  signs  of  arthritis  deformans  developed 
after  two  consecutive  operations,  in  which  the  fragment  and  then  the 
entire  cartilage  was  removed.  Bahr  also  saw  less  favorable  results. 
As  these  appear  to  be  rare,  they  do  not  form  a  counterindication  to 
operation. 


Vol.  in.— 38 


CHAPTER   XXXI. 

DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 
EXUDATIVE  INFLAMMATIONS  OF  THE  KNEE-JOINT. 

Acute  Serous  Synovitis. — Acute  serous  synovitis,  although  most 
frequently  due  to  contusion  or  sprain  of  the  joint,  may  follow  open 
or  subcutaneous  injuries  of  the  joint,  especially  puncture-wounds,  or 
occur  as  a  local  manifestation  of  rheumatism,  gonorrhoea,  scarlet  fever, 
smallpox,  typhoid,  and  erysipelas — in  the  latter  case  especially  if  the 
process  advances  over  the  joint;  also,  after  catheterization,  dilatation  of 
urethral  stricture,  lithotomy,  or  by  transmission  from  an  adjacent 
inflammation,  such  as  furuncle  or  purulent  prepatellar  bursitis. 

The  effusion  varies  considerably  in  amount,  is  often  profuse,  and  is  a 
yellow  clear  fluid  containing  albumin  and  a  few  white  and,  as  a  rule, 
a  few  red  blood-cells;  if  due  to  severe  trauma,  the  red  blood-cells  are 
increased,  the  exudation  becoming  yellowish-red  or  red  with  the  charac- 
ter of  a  hremarthrosis.  Fibrin  may  be  present  in  varying  amount,  the 
serum  being  fiocculent,  the  cartilage  and  synovialis  covered  with  deposit. 
The  synovialis  is  injected,  its  villi  slightly  red  and  swollen,  and  after 
trauma  contains  a  number  of  larger  or  smaller  ecchymoses.  The  fluid 
may  be  resorbed  and  the  joint  return  to  normal  in  a  few  days,  but 
unfortunately  as  the  result  of  injudicious  use  the  resorption  is  often 
only  partial  and  the  acute  condition  merges  into  a  subacute  or  chronic 
one. 

Acute  Seropurulent  Synovitis. — The  effusion  is  rarely  purely  serous, 
but  rather  seropurulent  in  synovitis  of  infectious  origin,  the  leucocytes 
being  increased,  the  serum  opalescent  or  cloudy.  This  is  seen  in  rheu- 
matism as  well  as  in  erysipelas,  puerperal  infections,  or  osteomyelitis  of 
the  femur  or  tibia. 

Acute  Purulent  Synovitis. — Purulent  synovitis  occurs  chiefly  after 
direct  infection  of  the  joint  in  wounds,  gunshot  fractures,  or  secondarily 
from  a  transmitted  suppuration,  as  in  purulent  osteomyelitis  of  the  epi- 
physis, rarely  acute  periarticular  phlegmon.  In  the  seropurulent  as  well 
as  purulent  form  the  synovialis  is  red  and  much  congested ;  the  inner  layer 
is  greatly  infiltrated  with  leucocytes;  the  villi  are  swollen  and  intensely 
red.  The  periarticular  tissues  are  swollen,  cedematous,  and  adherent  to 
the  skin;  the  contour  of  the  joint  is  obscured.  The  capsule  becomes 
intensely  infiltrated  with  pus,  ruptures,  and  phlegmon  and  fistulas  follow. 
The  perforation  sometimes  takes  place  in  the  upper  recess,  or  at  either 
side  of  the  patella,  or  into  the  bursa  poplitea  or  semimembranosa,  with 
the  formation  of  abscesses  or  fistulas  between  the  muscles  of  the  calf. 
(  594  ) 


EXUDATIVE  INFLAMMATIONS  OF  THE  KNEE-JOINT.       595 

The  surfaces  of  the  joint  are  involved  rather  early;  the  cartilage  is 
destroyed  in  patches,  replaced  by  granulations,  and  separated  from  the 
bone.  The  inflammation  then  spreads  to  the  spongiosa  of  the  femur,  or 
tibia. 

Symptoms. — The  picture  of  the  serous  synovitis  depends  essentially 
upon  the  effusion,  the  change  in  contour  being  the  same  as  would  be 
produced  by  injecting  water  into  the  joint;  the  depressions  at  the  sides 
of  the  patella  are  replaced  by  swellings  merging  together  above  the 
patella  and  corresponding  to  the  contour  of  the  capsule,  the  "upper 
recess"  extending  even  2h  to  3  inches  above  the  patella.  If  the  com- 
munication of  the  upper  recess  with  the  joint  is  narrow,  the  tumor  is 
more  hour-glass  shaped.  As  the  capsule  is  firm  behind,  swelling  in  the 
popliteal  space  is  rare  unless  the  exudate  is  very  great.  If  the  bursa? 
poplitea  and  semimembranosa  communicate  with  the  joint,  there  is  a 
hemispherical  swelling  behind  and  toward  the  side  of  the  joint. 

Fluctuation  varies  according  to  the  size  of  the  tumor;  it  is  best 
obtained  at  the  sides  of  the  patella  by  pressing  upon  the  upper  recess. 
If  the  bursa?  behind  communicate  with  the  joint,  through-fluctuation 
may  be  elicited.  With  the  knee  extended  and  relaxed,  the  familiar 
click  and  ballottement — "Tanzen" — of  the  patella  can  be  obtained ;  in 
flexion  the  patella  is  always  pressed  against  the  trochlea  even  if  the 
exudate  is  large.  If  the  exudate  is  slight,  the  click  can  be  elicited 
only  by  pressing  all  the  fluid  down  beneath  the  patella;  on  the  other 
hand,  it  may  be  prevented  by  the  tension  of  a  profuse  exudate,  but  in 
this  case  the  form  of  the  swelling  is  characteristic. 

The  soft  parts  are  unchanged  in  the  purely  serous  form;  the  skin  is 
normal,  but  may  be  slightly  warmer  than  the  other  knee.  If  the  exudate 
is  large,  the  knee  is  usually  held  slightly  flexed,  active  extension  being 
free,  flexion  slightly  limited.  Pain  is  absent  or  insignificant.  The 
only  functional  disturbance  may  be  slight  fatigue  on  exertion  and  a 
weak  feeling  in  the  limb,  especially  in  climbing  stairs.  Fever  is  absent 
in  pure  serous  synovitis,  especially  when  due  to  trauma,  and  present 
only  in  the  infectious  forms  and  in  monarticular  rheumatism,  and  then 
corresponds  to  the  general  infection  or  the  inflammation  adjacent  to  the 
joint- 
High  fever,  especially  if  continuous,  if  not  explained  by  complica- 
tions elsewhere,  always  arouses  suspicion  of  suppuration.  The  richer 
the  exudate  in  leucocytes,  the  earlier  the  involvement  of  the  tissues 
about  the  joint  and  the  picture  of  acute  purulent  synovitis,  as  is  usually 
seen  in  infected  wrounds  of  the  joint.  High  continuous  fever,  between 
102°  and  104°  F.,  is  ushered  in  with  one  or  more  chills.  The  joint 
becomes  painful,  and  motion  and  even  the  pressure  of  the  bedclothes 
is  avoided.  The  limb  is  soon  flexed  to  a  right  or  acute  angle.  The 
skin  over  the  joint  is  red,  glossy,  and  hot;  the  soft  parts  swollen  and 
oedematous,  concealing  the  form  of  the  distended  capsule.  Fluctuation 
and  ballottement  of  the  patella,  possibly  under  anaesthesia,  confirm  the 
diagnosis.  The  entire  leg  and  foot  may  be  oedematous  if  perforation 
occurs  and  phlegmon  follows.     The  constitutional  disturbance  corre- 


596  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

sponds  to  the  height  of  the  fever;  there  is  headache,  anorexia,  malaise, 
vomiting;  in  severe  cases  septic  diarrhoea,  delirium,  stupor  or  coma. 

v.  Volkmann  describes,  under  the  name  of  catarrhal  suppuration,  an 
acute  purulent  gonitis,  of  which  the  cause  is  unknown,  occurring  in 
young  children;  the  onset  is  spontaneous  with  fever  and  pain  in  the 
joint;  the  knee  is  flexed.  Aspiration  gives  a  tenacious  pus,  but  instead 
of  the  usual  periarticular  phlegmon  there  is  only  slight  oedema  of  the 
soft  parts.  The  symptoms  are  less  severe  and  recovery  follows  without 
incision. 

The  gonitis  resulting  from  metastases  (pyaemia,  puerperal  fever,  or 
erysipelas)  often  differs  from  the  acute  purulent  process  in  infected 
wounds.  There  is  fever,  constitutional  disturbance,  a  purulent  or 
seropurulent  effusion ;  the  joint  may  be  destroyed  early.  But  in  con- 
trast to  these  severe  anatomical  changes  the  pain  may  be  very  slight, 
and  the  attention  first  aroused  by  the  looseness  of  the  joint  and  the 
backward  dislocation  of  the  leg.  Movement  of  the  joint  is  intensely 
painful,  but  stiffness  is  usually  slight  or  absent.  In  contrast  to  the 
slight  subjective  disturbance  aspiration  will  verify  the  presence  of  pus. 

Gonorrhoeal  inflammation  of  the  knee  is  rather  frequent,  only  the 
wrist  being  affected  as  often.  Therefore  one  should  not  be  too  pre- 
vious with  the  diagnosis  of  monarticular  rheumatism,  for  the  supposed 
rheumatism  often  proves  to  be  a  sign  of  gonorrhoea.  Baur  found  the 
gonococcus  in  60  per  cent,  of  the  cases  of  gonorrhoeal  synovitis  up  to 
the  sixth  day  of  the  disease,  but  this  does  not  exclude  the  possibility  that 
a  non-gonorrhoeal  or  mixed  purulent  gonitis  may  occur  during  gonor- 
rhoea. The  knee  may  be  involved  secondarily  at  any  time  during 
the  urethritis,  but  usually  it  is  affected  in  the  first  week,  exceptionally 
after  the  disease  has  existed  some  time.  The  cessation  of  the  urethral 
discharge  with  the  onset  of  the  gonitis  and  its  recurrence  after  the 
latter  has  subsided,  although  observed  frequently  has  not  been  ex- 
plained. The  inflammation  may  be  serous  and  subside  in  a  few  days 
under  appropriate  treatment,  or  purulent,  the  effusion  being  cloudy 
from  the  first  with  leucocytes  and  fibrin,  the  capsule  and  cartilage 
being  covered  with  deposit.  On  incising  the  joint  the  fibrin  may  be 
removable  in  large  strips.  Occasionally  the  effusion  is  entirely  purulent; 
the  soft  parts  are  swollen  early,  the  ligaments  and  capsule  infiltrated 
with  leucocytes,  the  skin  and  subcutis  cedematous.  The  effusion  may  be 
slight  or  profuse,  and  so  suggest  tuberculosis,  especially  if  of  long  standing. 
The  pain  is  very  intense.  At  the  onset  fever  is  common.  Profuse 
exudation  with  distention  and  destruction  of  the  capsule  are  liable  to 
be  followed  by  backward  subluxation  of  the  leg.  If  the  exudate  is 
slight,  stiffening  is  probable — in  fact,  is  often  unavoidable,  on  account 
of  the  shrinkage  of  the  capsule  and  the  adhesions  between  the  joint- 
surfaces.  The  cartilage  is  destroyed  early  by  the  fibrin  deposits,  the 
bone  becomes  involved;  fibrous  or  even  bony  ankylosis  may  follow  in  a 
few  weeks,  the  patella  especially  being  liable  to  become  adherent  to  the 
condyles  at  an  early  period.  The  disease  is  therefore  serious,  its  prog- 
nosis doubtful,  and  the  treatment  very  important. 


/.A  r  DATIVE  INFLAMMA  TIONS  OF  THE  KNEE-JOINT.        597 

Course. — The  course  of  the  various  exudative  inflammations  of  the 
knee-joint  depends  essentially  upon  the  nature  and  severity  of  the  disease 
and  upon  the  treatment.  Simple  acute  serous  synovitis  usually  heals  in  a 
short  time  unless  the  joint  is  not  rested  properly,  in  which  case  a  chronic 
hydrarthrosis  may  result  and  more  or  less  fluid  remain  in  the  joint  or 
return  every  time  the  limb  is  used.  The  synovialis  then  becomes  more 
thickened;  the  villi  are  enlarged  and  often  contain  cartilage-cells;  the 
cartilage  becomes  somewhat  fibrous;  the  exudate  is  thin  with  few  cells. 

Chronic  hydrarthrosis  is  recognizable  chiefly  by  the  swelling  in  the 
joint  and  the  absence  of  such  about  the  joint.  Fluctuation  and  bal- 
lottement  of  the  patella  are  easily  obtained;  subjective  symptoms  are 
slight;  pain  may  be  absent  or  be  produced  by  pressure  and  motion. 
The  mobility  of  the  joint  is  seldom  impaired;  the  patient  merely  has  a 
feeling  of  weakness  and  uncertainty  in  the  limb  and  is  unable  to  lift 
heavy  weights.  But  the  earning-efficieney  is  thereby  considerably 
compromised.  Objectively  the  early  atrophy  of  the  quadriceps  and 
weakness  of  the  limb  are  noticeable;  later,  after  the  ligaments  have 
become  relaxed,  the  looseness  of  the  joint,  especially  the  lateral  mobility 
possible  with  the  knee  extended. 

Complete  recovery  cannot  be  expected  if  the  exudate  is  not  purely 
serous,  unless  treatment  is  begun  early,  except  in  the  cases  of  so-called 
catarrhal  suppuration  in  children.  The  seropurulent  and  purulent  forms, 
even  with  proper  treatment,  are  usually  followed  by  a  certain  amount  of 
stiffness  whose  removal  may  be  more  or  less  effectually  accomplished 
by  proper  treatment,  exercise,  and  use,  but  which  nevertheless  makes 
demands  upon  the  physician  and  patient  that  are  not  always  met.  One 
is  fortunate  if  able  to  prevent  a  contracture,  backward  dislocation,  a 
varus,  or,  more  commonly,  a  valgus  position  and  the  consequent  severe 
functional  disturbance.  The  tendency  of  gonorrhceal  gonitis  to  fibrous 
or  bony  ankylosis  has  been  mentioned.  In  the  severe  forms  of  septic 
suppuration  following  wounds,  osteomyelitis,  etc.,  early  energetic 
treatment  is  required  to  preserve  even  a  fair  amount  of  motion.  If  the 
cartilage  is  eroded  or  destroyed,  the  final  result  should  be  considered 
good  if  the  patient  has  a  stiff  but  useful  limb  with  the  knee  extended 
after  resection. 

Treatment. — The  majority  of  surgeons  at  the  present  time  treat 
exudative  gonitis  in  about  the  same  way.  Immobilization  in  a  plaster- 
splint  is  seldom  employed  except  in  very  painful  cases  with  slight  or  no 
effusion.  The  acute  serous  effusions  as  a  rule  only  require  rest  for 
several  days  in  a  tin-  or  wire-splint,  with  the  application  of  moist  heat 
and  pressure.  Konig  applies  tincture  of  iodine  thickly  till  the  skin  is 
dark  brown,  and  then  an  ice-bag.  As  soon  as  the  effusion  is  resorbed 
gentle  passive,  and  then  active,  motion  is  begun,  but  the  patient  is  not 
allowed  to  walk  until  motion  is  without  pain.  Salicylic  acid  is  some- 
times beneficial  the  same  as  in  polyarticular  rheumatism. 

If  resorption  is  delayed  or  a  seropurulent  effusion  is  manifested  by 
fever,  periarticular  swelling  and  intense  pain,  aspiration  with  a  large 
needle,  or,  better,  a  trocar,  is  indicated,  preferably  at  the  outer  side  of 


598  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

the  upper  recess;  a  2  to  3  per  cent,  solution  of  carbolic  acid  is  then 
injected,  allowed  to  escape  entirely,  and  the  puncture-wound  sealed  with 
iodoform  collodion.  Many  prefer  the  injection  of  10  to  20  drops  of 
tincture  of  iodine,  of  1  to  2\  drachms  of  Lugol  solution,  or  of  1  to  2\ 
drachms  of  iodoform-glycerin  emulsion.  The  latter  has  given  the  author 
very  good  results.  A  dressing  is  then  applied  with  slight  pressure  and 
the  limb  immobilized  on  a  strip  splint  for  three  to  five  days;  later,  careful 
motion  and  massage.  As  a  rule  the  injection  or  lavage  is  followed  by 
slight  rise  of  temperature  for  one  or  two  days. 

If  suppuration  finally  develops  or  is  suspected  at  the  outset,  it  is 
advisable  to  puncture  to  verify  the  diagnosis,  and  then  to  incise  and 
drain.  Two  longitudinal  incisions  (f  to  \\  inches  long)  are  made  at 
either  side  of  the  quadriceps  tendon,  the  upper  recess  is  opened,  and 
two  incisions  also  made  below  the  patella  in  front  of  the  lateral  liga- 
ments. The  joint  is  washed  out  thoroughly  with  a  3  per  cent,  boric 
acid  or  salt  solution,  a  large  drainage-tube  inserted  transversely  through 
the  upper  wounds,  and  two  shorter  ones  in  the  lower  openings  not  long 
enough  to  be  caught  between  the  joint-surfaces.  A  dry  dressing  is  ap- 
plied and  the  limb  placed  in  a  Volkmann  splint.  Exceptionally  it  is 
necessary  to  drain  posteriorly;  Oilier  makes  two  lateral  incisions  behind 
the  condyles,  the  outer  at  the  anterior  border  of  the  biceps  tendon,  the 
inner  between  the  semitendinosus  and  semimembranosus,  and  in  severe 
cases  recommends  opening  the  joint  in  front  and  removing  the  crucial 
ligaments.  The  incision  behind  may  be  made  by  dissecting  through 
the  popliteal  space.  In  such  severe  cases  free  motion  is  not  to  be 
expected.  Instead  of  the  above  customary  four  short  incisions,  two 
long  lateral  incisions  curved  convexly  backward  may  be  made  at  both 
sides  of  the  extensors  and  the  joint  opened  in  its  entire  length;  instead 
of  draining,  the  cavity  may  be  packed  loosely  with  iodoform  gauze. 

Resection  is  indicated  if  the  joint-surfaces  are  destroyed  and  the 
cartilages  detached  as  in  cases  of  fracture  with  suppuration — for  exam- 
ple, gunshot  fractures.  Ankylosis  is  inevitable.  Amputation  is  indi- 
cated by  rapid  extension  of  a  local  septic  infection  or  by  symptoms  of 
general  infection.  Attempts  to  preserve  the  limb  by  incision  and 
drainage  or  resection  in  such  dread  cases  are  usually  paid  for  with  the 
life  of  the  patient.  It  is  therefore  very  important  not  to  carry  con- 
servative treatment  too  far. 

The  contracture  left  after  exudative  synovitis  offers  a  varying  amount 
of  resistance  to  treatment.  In  the  mild  serous  cases  it  is  naturally 
slight,  and  usually  disappears  rapidly  with  use;  in  the  seropurulent  or 
purulent  cases  with  fibrin,  especially  the  gonorrhceal  cases,  it  may  be 
very  stubborn  and  be  overcome  only  by  persistent  and  continuous 
methodical  exercise.  Passive  and  active  motion  should  be  gentle  at 
first,  and  increased  daily  according  to  the  pain  and  reaction.  At  the 
beginning  the  joint  is  bandaged  each  time  after  being  exercised  and  a 
hot  wet  compress  applied  regularly  at  night.  Renewed  effusion  may 
follow  the  first  active  exercise,  especially  after  protracted  immobili- 
zation ;    if  slight,   it    should   not    prevent   careful    use  ;    otherwise,    if 


EXUDATIVE  INFLAMMA  TIONS  OF  THE  KNEE-JOINT.       599 
marked  and  accompanied  by  fever,  immobilization  and  aspiration  are 

indicated. 

The  intense  pain  often  produced  by  passive  motion  may  delay  recovery 
or  prevent  further  treatment  in  the  ease  of  sensitive  people  without 
will-power.  Nevertheless  unexpected  improvement  may  occur  even 
in  such  patients  in  the  course  of  a  year  or  more;  in  others  stiffness 
ensues.  As  bony  ankylosis  becomes  established,  the  use  of  the  limb 
becomes  less  and  less  painful;  on  the  other  hand,  a  joint  stiffened  by 
fibrous  adhesions  with  a  mobility  of  perhaps  10  to  30  degrees  is  often 
extremely  sensitive  and  disables  the  patient  for  a  long  time.  Forcible 
separation  of  the  adhesions  may  be  attempted  under  anaesthesia,  the 
joint  then  being  wrapped  in  wet  compresses  and  immobilized  for 
twenty-four  to  forty-eight  hours,  but  success  presupposes  a  patient 
with  a  strong  will  and  ability  to  endure  the  protracted  pain  of  subse- 
quent treatment.  On  account  of  this  difficulty  of  overcoming  estab- 
lished stiffness  the  mobilization  of  the  joint  should  be  begun  at  the 
earliest  possible  moment,  namely,  a  few  days  after  aspiration  or  lavage, 
or  after  incision,  as  soon  as  the  fever  disappears  and  the  pain  becomes 
tolerable.     The  time  must  be  determined  in  the  individual  case. 

Chronic  Synovitis. — Simple  hydrarthrosis  is  favorably  influenced  by 
pressure  by  means  of  a  rubber  bandage,  as  in  the  case  of  rnemarthrosis, 
or  sponges,  but  is  liable  to  return  as  soon  as  the  pressure  is  discontinued. 
Lavage  of  the  joint  with  a  3  per  cent,  carbolic  acid  solution  deserves 
more  general  use;  the  joint-capsule  should  be  moderately  distended 
and  manipulated  and  the  joint  moved  to  bring  the  fluid  in  contact 
with  all  parts  of  the  affected  capsule;  the  solution  is  then  aspirated  and 
fresh  injected  until  it  returns  clear.  It  is  then  entirely  expelled  by  light 
pressure  and  a  pressure-bandage  applied  and  wrorn  for  about  eight 
days.  Not  infrequently  the  fluid  reaccumulates  in  five  or  six  days,  even 
while  the  patient  is  in  bed  and  the  joint  under  pressure;  if  it  does  not 
disappear  under  massage  and  pressure,  a  second  or  even  third  wash- 
ing may  be  necessary.  The  effusion  not  infrequently  yields  to  this 
treatment  if  the  case  is  not  too  old.  Since  this  procedure  was  intro- 
duced by  v.  Volkmann  the  injection  of  tincture  of  iodine  (Bonnet,  Vel- 
peau,  and  others)  has  been  less  used;  with  the  latter  there  wras  always 
a  strong  reaction — pain,  marked  swelling,  redness,  and  slight  fever  for 
one  or  two  days.  Still,  the  method  has  given  good  results  in  many 
stubborn  cases  in  which  other  measures  failed,  and  should  therefore  be 
remembered.  Injection  of  10  per  cent,  iodoform-glycerin  (iodoform  oil) 
has  often  been  successful  in  non-tuberculous  cases;  the  irritation  is 
slight.  For  several  weeks  after  puncture  the  knee  should  always  be 
bandaged  with  flannel,  or  a  woven  or  elastic  knee-cap  worn.  In  severe 
cases  it  is  better  to  have  the  patients  wear  and  go  about  in  a  silicate- 
splint  or  a  leather  sheath  supporting  apparatus.  Heidenhain  recom- 
mended Unna's  zinc-gelatine  dressing  (Zinkleim  Verband);  it  is  very 
serviceable  for  clinical  or  poor  patients. 

Intermittent  Hydrops. — Intermittent  hydrops  is  a  rare  form  of  exu- 
dative synovitis  of  the  knee  which  is  little  known  and  the  nature  of 


600  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

which  is  still  unexplained.  Two  years  ago  Benda  could  collect  only 
56  cases  of  this  sort;  it  occurs  chiefly  in  the  knee-joint  and  in  one  or 
both  knees,  with  the  symptoms  of  an  acute  serous  synovitis;  in  14 
instances  the  knees  were  affected  consecutively.  The  peculiarity  of  the 
affection  is  its  periodic  recurrence  at  intervals  of  eleven  to  thirteen 
days,  less  frequently  of  seven  to  nine  days,  or  of  four  weeks;  single 
instances  of  other  variations  are  given.  The  swelling  usually  lasts  three 
days;  occasionally  also  associated  with  swelling  of  the  skin  of  the  thigh 
or  face.  Shortly  after  the  fluid  has  disappeared,  or  even  before,  a  new 
attack  occurs  without  apparent  cause.  Rapidly  following  attacks  cause 
a  certain  amount  of  fluid  to  be  left  permanently.  The  number  of  attacks 
varies  greatly,  their  frequency  and  course  being  little  influenced  by 
treatment.  They  may  cease  as  suddenly  as  the  first  attack  appeared 
and  not  recur  for  many  weeks  or  months. 

Little  is  known  positively  as  to  the  cause  of  this  peculiar  affection  or 
its  striking  periodicity.  There  is  apparently  no  latent  malaria  as  one 
might  suspect;  disturbances  of  the  nervous  system  seem  to  play  a  cer- 
tain part  in  the  etiology.  Local  treatment  is  practically  powerless  to 
prevent  new  attacks,  so  that  one  is  dependent  chiefly  upon  the  general 
treatment;  quinine,  arsenic,  potassium  iodide,  warm  baths,  hot  spring 
baths,  and  hydrotherapy  have  been  useful  in  some  cases,  but  just  how  is 
hard  to  determine,  as  spontaneous  recovery  has  also  occurred.  The 
affection  may  kst  for  years  and  cause  severe  functional  disturbance. 


TUBERCULOSIS   OF   THE  KNEE-JOINT. 

All  the  forms  and  peculiarities  of  joint-tuberculosis  occur  with  such 
frequency  in  the  knee  that  this  joint  is  the  best  for  studying  tuberculous 
arthritis,  with  the  exception  of  the  rare  caries  sicca.  Children  and 
adolescents  are  most  commonly  affected.  According  to  Konig's  statistics 
of  704  patients,  292  were  in  the  first  decade,  190  in  the  second,  and  93 
in  the  third,  males  being  affected  (59  per  cent.)  somewhat  more  fre- 
quently than  females  (41  per  cent.).  The  right  and  left  knee  were 
apparently  diseased  equally  often.  As  to  the  origin  being  in  the  syno- 
vialis  or  the  bone,  authors  are  not  agreed;  Konig  estimates  281  cases 
as  being  osseous,  351  as  synovial,  and  29  as  undeterminable,  among 
661  cases.  Slight  trauma,  simple  contusion,  and  sprain  are  given  as  the 
cause  in  about  20  per  cent,  of  the  cases;  usually  there  is  evidence  of 
heredity  or  tuberculous  foci  elsewhere. 

Pathological  Anatomy. — In  tuberculosis  of  the  synovialis,  whether 
primary  or  secondary,  the  changes  are  the  same  as  to  quality  and  vary 
only  in  as  far  as  the  effusion  or  the  granulations  predominate.  The 
process  apparently  starts  as  a  rule  with  the  increased  production  of 
synovia  rich  in  fibrin,  the  fluid  rarely  being  as  clear  as  that  of  serous 
synovitis.  It  may  be  slight  or  so  profuse  as  to  be  termed  properly  a 
tuberculous  hydrops.  From  the  onset  it  is  more  or  less  cloudy,  the 
particles  of  fibrin  varying  from  the  finest  flocculi  to  large  flakes  and 


TUBERCULOSIS  OF  THE  KNEE-JOINT. 


601 


threads  which  may  coalesce  to  form  firm  or  soft  grayish-white  masses  of 
round  or  oval  shape,  the  size  of  a  pinhead,  pea,  or  bean,  the  so-called 
rice-bodies.  In  the  early  stage  the  synovialis  is  red  and  swollen;  the 
cartilage  is  covered  at  typical  spots  with  thin  transparent  membranes 
spreading  out  over  the  synovialis  from  the  junction  of  the  cartilage  and 
capsule,  the  typical  spots  being  on  the  lower  front  surface  of  the  condyles 
of  the  femur  below  the  patella,  where  the  trochlear  surface  joins  that 
of  the  condyles,  namely,  at  the  point  where  the  cartilages  of  the  femur 
and  tibia  are  not  in  contact.  This  fibrinous  deposit  later  becomes 
vascular  and  dotted  everywhere  with  tuberculous  nodules,  but  especially 
along  the  edges  of  the  cartilage.  (Konig.)  The  synovialis  and  cartilage 
thus  become  covered  with  granulations.     Goldmann  and  others,  against 


Fig.  375. 


Surface  of  the  femur  divided  into  three  parts  by  granulation-tissue.     CKiinig.) 

this  view  of  Konig's,  believe  that  the  changes  are  due  to  degeneration 
of  the  synovialis.  The  process  may  be  localized  and  limited  to  one  or 
more  portions  of  the  joint,  the  cartilages  becoming  adherent  and  the 
foci  walled  off,  or  the  cartilage  and  bone  may  be  destroyed  progressively. 
(Fig.  375.)  At  one  or  more  places  on  the  synovialis  there  may  be  a 
circumscribed,  or  diffuse,  and  often  exuberant,  proliferation  of  the  villi, 
forming  grayish-red,  or  gray,  fairly  firm  polypoid  growths  of  various 
shapes  and  sizes.  (Fig.  376.)  Their  groundwork  consists  of  connective 
tissue  and  vessels;  the  subsynovial  adipose  tissue  may  be  involved  in 
the  growth,  even  to  the  extent  of  forming  tumors  almost  entirely  com- 
posed of  fat  (lipoma  arborescens ) .  In  rare  instances  there  is  a  circum- 
scribed, nodular,  tumor-like  proliferation  of  connective  tissue  at  one  or 
more  spots  on  the  synovialis,  the  so-called  tuberculous  fibroma  (Riedel, 
Konig),  attaining  the  size  of  a  walnut,  and  consisting  partially  of  fatty 


602 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


degenerated  connective  tissue  or  of  tuberculous  nodules  separated  by 
a  large  number  of  thick-walled  vessels. 

The  cartilage  is  apparently  passive  in  the  process;  at  first  it  loses  its 
normal  gloss  and  smoothness,  then  shows  small  defects,  which  as  the 
granulations  develop  become  more  numerous,  spread,  and  deepen  until 
the  cartilage  is  finally  perforated  in  places.  In  these  spots  the  granu- 
lation-tissue attacks  the  bone.  The  granulations  also  advance  between 
the  cartilage  and  the  bone,  especially  at  the  attachments  of  the  lateral 
ligaments,  loosening  the  cartilage  from  its  base  until  it  is  often  completely 

Fig.  376. 


Growth  of  synovial  villi  in  tuberculous  knee-joint.     (Konig.) 

destroyed.  (Fig.  377.)  The  spongiosa  of  the  bones  undergoes  a  rare- 
fying ostitis,  which,  according  to  Konig,  may  not  be  tuberculous ;  it  may 
occur  in  the  absence  of  primary  foci  in  the  bone  or  without  the  tuber- 
culous granulations  having  perforated  or  undermined  the  cartilage. 
Once  having  penetrated  into  the  bone  the  process  produces  the  same 
changes  found  in  the  primary  tuberculous  granulation  foci. 

Primary  tuberculosis  of  the  bone  is  seen  in  the  condyles  of  the  femur, 
the  tuberosities  of  the  tibia,  and  less  frequently  in  the  patella,  in  which 
latter  it  is  either  in  the  form  of  a  granulating  focus  or  a  sequestrum, 
rarely  a  progressive  infiltration.     Large  wedge-shaped  sequestra  are 


TUBERCULOSIS  OF  THE  KNEE-JOINT. 


603 


met  with  in  the  tuberosities  of  the  tibia,  with  the  base  usually  toward 
the  joint,  and  occasionally  in  the  condyles  of  the  femur;  the  cartilage 
is  rapidly  destroyed,  but  if  the  joint  is  used,  the  surface  becomes  polished. 
Perforation  of  an  osseous  focus  into  the  joint  depends  upon  its  relation 
to  the  capsule;  the  majority  of  foci  lead  secondarily  to  tuberculosis  of 
the  synovialis,  although  extra-articular  perforation  does  occur.  A  typical 
focus,  frequently  advancing  outside  of  the  joint,  is  found  in  the  head 
of  the  tibia,  perforation  usually  taking  place  either  forward  into  the 
subpatellar  bursa  beneath  the  attachment  of  the  ligamentum  patella?, 
or  laterally  below  the  insertions  of  the  semimembranosus  and  tendinosus, 
or,  rarely,  behind  into  the  popliteal  space;  perforation  into  the  joint 
alone  or  combined   with   perforation    outward    is    not    rare,  however. 

Fig.  377. 


Deep  destruction  of  cartilage  and  bone  in  the  area  covered  by  deposits,  with  numerous  foci  of 

necrosis.      (KiJnig.) 

Primary  foci  in  the  epicondyles  may  perforate  laterally  or  backward 
without  infecting  the  capsule;  if  forward  or  downward,  the  joint  is 
necessarily  involved.  Foci  in  the  patella,  although  they  often  perfor- 
ate forward,  lead  rather  frequently  to  secondary  tuberculosis  of  the 
synovialis,  either  directly  or  by  the  formation  of  a  periarticular  abscess. 
The  site  of  the  osseous  foci  was  found  by  Konig,  in  281  cases,  in  the 
patella  in  33,  in  the  femur  in  93,  in  the  tibia  in  107,  and  in  several  bones 
in  48.  The  fibrous  capsule  of  the  joint  forms  a  protective  wall  against 
the  dissemination  of  synovial  tuberculosis,  so  that  the  process  cannot 
perforate  unless  suppuration  occurs;  this  is  never  the  case  in  simple 
tuberculous  synovitis.  Perforation,  although  it  may  take  place  at  any 
point,  is  most  frequent  at  the  upper  recess,  at  the  sides  of  the  patellar 
ligament,  and  behind  into  the  bursa  poplitea  or  semimembranosa.  Cold 
abscesses,  often  very  extensive,  may  then  form  either  in  front  beneath 


604  DISEASES  IN  AND  ABOUT  THE  KNEE-JOIST. 

the  vasti  or  behind  beneath  the  muscles  of  the  calf.  Periarticular 
abscesses  which  do  not  involve  the  joint  are  apparently  always  the  result 
of  perforation  of  primary  osseous  foci;  such  abscesses  have  often  been 
incised  and  scraped  out,  however,  without  any  diseased  bone  being 
found,  and  have  recovered. 

Synovial  tuberculosis  may  recover  at  any  stage  if  transformed  into 
connective  tissue  with  shrinkage  of  the  granulations,  but  rarely  if  there 
is  extensive  caseation  of  the  fibrin  or  suppuration,  although  even  then 
it  is  not  impossible.  Large  osseous  foci  retard  recovery;  large  sequestra 
make  it  impossible,  although  temporarily  there  may  be  an  apparent 
recovery.  Normal  mobility  is  rarely  restored  except  in  very  mild  cases 
in  youth,  the  destruction,  partial  or  complete,  of  the  articular  surfaces, 
the  adhesions  and  the  shrinkage  of  the  capsule,  always  entailing  more 
or  less  functional  loss. 

Symptoms. — Clinically,  primary  osseous  and  primary  synovial  tuber- 
culosis are  very  seldom  distinguishable  from  each  other.  The  former 
gives  almost  no  symptoms;  usually  there  is  only  slight  dull  pain,  increased 
by  pressure,  until  the  joint  becomes  involved  and  the  synovitis  produces 
symptoms  and  discomfort  that  cause  the  patient  to  seek  medical  aid. 
The  osseous  form  is  occasionally  diagnosed  before  the  synovialis 
is  involved  if  the  focus  is  superficial  and  the  bone  is  thickened  or  cold 
abscesses  have  formed.  This  applies  especially  to  foci  in  the  head  of 
the  tibia,  to  those  in  the  patella  in  which  the  focus  perforates  forward, 
and  to  circumscribed  foci  in  the  epiphysis  of  the  femur  perforating 
laterally  outside  of  the  joint. 

The  clinical  picture  is  dominated  by  the  synovial  tuberculosis,  whether 
primary  or  secondary.  Three  varieties  are  distinguishable:  (a)  tuber- 
culous hydrops;  (b)  granulation  tuberculosis  or  fungus  of  the  joint;  (c) 
cold  abscess  of  the  joint.  Although  the  three  forms  merge  into  each 
other,  this  classification  is  valuable  practically. 

The  tuberculous  hydrops  is  characterized  by  the  effusion,  and  is  essen- 
tially the  same  clinically  as  serous  synovitis,  already  described,  so  that 
the  tuberculous  nature  of  the  affection  is  indicated  less  objectively  than 
bv  the  accompanying  moments,  namely:  1.  The  youth  of  the  patient, 
simple  hydrops  occurring  chiefly  in  adults,  although  it  occurs  excep- 
tionally in  youth  even  as  the  tuberculous  hydrops  is  often  seen  in  adults. 
2.  Tuberculous  heredity.  3.  Scrofulous  habitus  or  the  existence  of  tuber- 
culous processes  elsewhere.  4.  The  appearance  of  the  effusion  sponta- 
neously without  fever,  or  after  slight  trauma,  contusion,  or  sprain;  the 
exclusion  of  gonorrhoea,  arthritis  deformans,  or  previous  rheumatism. 
5.  The  persistence  or  constant  recurrence  of  the  effusion  in  spite  of  the 
appropriate  treatment  to  which  simple  hydrops  usually  yields.  None 
of  these  facts  is  conclusive  per  sc,  but  taken  together,  especially  after 
longer  observation,  they  make  the  diagnosis  probable.  In  some  cases 
the  -welling  is  more  positively  tuberculous;  usually  the  capsule  is  more 
distended  than  in  simple  synovitis,  the  thickening  being  most  distinct 
in  the  lateral  folds  or  the  upper  recess.  By  stroking  the  fluid  from  the 
sides  into  the  upper  recess  or  in  the  opposite  direction  a  soft  rubbing 


TUBERCULOSIS  OF  THE  KSEE-JOIST.  605 

can  often  be  felt,  and  by  moving  the  joint  a  distinct  "  snow-hall  crunch- 
ing" or  coarse  crepitation  of  the  larger  rice-bodies.  The  aspiration 
of  cloudy  fluid  filled  with  fibrinous  flocculi  is  positive. 

The  fungous  variety,  according  to  Konig,  represents  the  second  stage 
of  the  disease,  and  is  always  preceded  by  the  hydrops.  Although  Konig 
has  seen  many  such  cases,  it  is  questionable  whether  this  sequence 
always  occurs,  as  one  meets  with  cases  enough  giving  only  the  symptoms 
of  granular  proliferation  without  any  evidence  in  the  history  of  previous 
hydrops.  In  the  fungous  form  there  is  always  some  effusion,  but  it  is 
insignificant  compared  to  the  granulations  and  consequent  thickening 
of  the  capsule.  The  upper  recess  is  therefore  not  so  sharply  defined; 
the  uniform  swelling  of  the  capsule  is  more  noticeable  at  the  cleft  of 
the  joint.  This,  in  connection  with  the  early  atrophy  of  the  muscles, 
especially  the  quadriceps,  gives  the  spindle-form  so  characteristic  of 
"fungus."  Or  the  process  and  the  thickening  may  be  limited  to  some 
part  of  the  joint  and  give  an  appearance  similar  to  that  of  sarcoma  of 
the  condyle.  Generally,  however,  the  circumscribed  as  well  as  the 
diffuse  swelling  is  not  very  sharply  defined,  although  one  can  feel  the 
folds,  namely,  the  attachments  of  the  synovialis,  very  distinctly  in  cases 
in  which  the  structures  about  the  joint  are  still  uninvolved. 

The  consistence  of  the  tumor  is  usually  firm.  Fluctuation  and  bal- 
lottement  of  the  patella  are  absent.  The  cases  with  very  exuberant  and 
rapid  formation  of  granulations  with  caseation  and  suppuration  are  not 
rare;  the  swelling  often  resembles  that  of  simple  hydrops  in  form  and 
consistence,  the  upper  recess  being  distended  and  often  giving  pseudo- 
fluctuation  from  the  softness  of  the  granulations. 

If  caseation  and  suppuration  develop,  the  inflammation  spreads 
rapidly  to  the  fibrous  capsule  and  the  tissues  about  the  joint,  which 
become  oedematous,  thickened,  and  augment  the  characteristic  spindle- 
form;  the  skin  becomes  thinner,  pale,  glossy,  and  the  subcutaneous  veins 
more  distinct.  To  this  picture  of  fungous  inflammation  the  very  appro- 
priate term  "tumor  albus"  was  applied  formerly. 

The  function  of  the  joint  is  little  impaired  by  the  hydrops,  only  the 
extreme  movements  being  impossible,  whereas,  in  fungous  tuberculosis 
motion  is  considerably  limited  and  a  contracture  in  slight  flexion 
occurs  early.  The  degree  of  flexion  varies;  exceptionally — in  fact,  only 
in  the  event  of  suppuration — the  knee  is  soon  flexed  to  a  right  angle, 
or  further,  as  often  observed  in  the  cases  of  acute  suppuration  of  the 
joint;  usually  it  remains  flexed  at  an  angle  of  about  130  to  1G0 
degrees  for  a  long  time,  the  angle  gradually  becoming  more  acute. 
The  limb  is  held  fairly  immovable  in  this  position;  active  motion  is 
avoided  or  limited;  passive  motion  usually  evokes  strong  muscular 
resistance,  motion  being  greatly  limited,  however,  even  under  anaes- 
thesia, by  the  intra-articular  adhesions  and  shrinkage  of  the  capsule. 
Beside  flexion  there  is  usually  a  varying  amount  of  abduction  and  out- 
ward rotation,  namely,  a  valgus  position.  This  is  found  also  with  pure 
synovial  tuberculosis,  so  that  destruction  of  the  bones  of  the  joint  can 
be  presumed  therefore  only  from  a  high  grade  valgus  position  of  rapid 


606 


DISEASES  IX  AXD  ABOUT  THE  KNEE-JOINT. 


development.  Persistence  of  the  contracture  leads  regularly  to  erosion 
of  the  contiguous  surfaces  of  the  femur  and  tibia,  chiefly  the  outer 
posterior  portion.  A  varus  position  is  more  rare;  if  pronounced,  it 
always  denotes  destruction  of  the  inner  condyle  or  tuberosity  or  both. 
The  rare  genu  recurvatum  and  frequent  backward  subluxation  of  the 
leg,  which  are  a  result  of  the  disease  and  the  treatment,  rather  than  a 
part  of  the  disease,  will  be  described  later. 

In  spite  of  the  contracture  the  patient  may  be  able  to  use  the  limb  for 
a  long  time.     The  pathological  position  is  chosen  and  maintained  by 


Fig.  379. 


Acute  tuberculous  arthritis  of  the  knee. 
(Whitman.) 


Tuberculous  disease  of  the  knee  in  an  adult. 
The  synovial  type.     (Whitman.) 


the  patient  to  a  certain  extent  to  alleviate  the  pain,  and  is  therefore  an 
expression  of  the  painfullness  of  the  joint;  in  fact,  the  valgus  position 
is  to  be  regarded  partly  as  a  direct  consecutive-symptom  of  the  weight- 
ing of  the  limb  flexed  at  the  knee.  In  some  instances  the  limb  is  pro- 
tected from  the  outset  by  using  crutches  or  by  staying  in  bed;  in  others 
the  patient  limps  about  with  a  cane  for  months  or  years.  This  differ- 
ence is  due  not  only  to  the  varying  will-power  or  negligence  of  the 
patient,  but  also  to  the  fact  that  the  pain  differs  in  individuals. 


TUBERCULOSIS  OF  THE  KNEE-JOINT.  607 

As  mentioned,  complete  absence  of  effusion  is  rare  in  a  tuberculous 
knee-joint;  in  about  one-half  the  cases  it  is  purulent.  Caseation  and 
purulent  fusion  take  place  first  in  the  unorganized  fibrinous  deposits  or 
granulations  upon  the  synovialis  or  cartilage.  The  abscess  thus  formed 
may  perforate  directly  outward  through  the  fibrous  capsule  and  lead  to 
a  periarticular  abscess  without  the  joint  necessarily  containing  pus; 
more  frequently  it  perforates  into  the  joint  alone  or  outward  at  the 
same  time.  In  the  joint  the  suppuration  may  be  circumscribed  or  diffuse. 
The  cause  of  suppuration  is  still  unknown,  disregarding  infection  by 
aspiration,  etc.  In  the  absence  of  fistulas  or  periarticular  abscesses 
the  diagnosis  of  tuberculous  joint  suppuration  is  usually  uncertain. 
Continuous  slight  fever  in  the  absence  of  other  causes  makes  it  probable, 
the  temperature  usually  being  normal  or  only  slightly  increased  in  the 
morning,  in  the  afternoon  varying  between  100.4°  and  101.2°  F.  The 
general  condition  suffers,  the  appetite  decreases,  the  skin  becomes  pale, 
the  patients  lose  slowly  but  visibly.  After  perforation  outward  and  the 
formation  of  a  fistula  the  fever  sometimes  disappears,  the  patient 
improves,  the  process  comes  to  a  standstill.  Often  secondary  infection 
occurs,  however;  the  pus  putrefies  and  becomes  foul,  and  the  fever 
becomes  continuous  and  high  with  the  signs  of  local  and  general  sepsis. 

Cold  abscess  of  the  joint,  although  rare,  is  not  to  be  confused  with 
the  frequent  suppuration  of  the  fungous  joint;  it  is  less  frequent  in  the 
knee  than  in  the  hip,  and  occurs  chiefly  in  young  children  other- 
wise tuberculous;  it  is  occasionally  bilateral.  The  synovialis  is  only 
slightly  swollen,  but  filled  with  miliary  tubercles;  it  is  covered  with  a 
thick  loosely  attached  abscess  membrane  and  greatly  distended  by  a 
thin  fluid  effusion.  The  form  of  the  joint  is  similar  to  that  in  hydrops, 
and  likewise  lacks  any  tendency  to  perforation  and  periarticular  phleg- 
mon. The  diagnosis  may  be  difficult,  especially  as  fever  may  be  absent, 
but  is  usually  aided  by  the  poor  general  condition,  multiple  lesions,  youth 
of  the  patient,  and  the  marked  swelling  of  the  synovialis;  aspiration  also 
helps  in  doubtful  cases. 

Course  — Spontaneous  recovery  may  occur  at  any  stage  of  tuberculosis 
of  the  knee-joint  except  with  very  large  osseous  foci  or  sequestra;  it  is 
prevented  by  suppuration  of  the  granulations.  Hydrops  and  the  fungous 
variety  with  dry  compact  granulations  which  have  a  tendency  to  shrink- 
age give  the  best  prospects  of  recovery;  they  may  heal  possibly  in  one 
to  three  years,  although  very  often  the  disease  lasts  considerably  longer 
and  the  recovery  is  only  apparent,  the  slightest  blow  often  sufficing  to 
occasion  renewed  pain  and  lighting  up  of  the  old  process.  That  such 
apparent  recovery  is  seen  rather  frequently  can  be  readily  understood 
from  the  pathological  conditions,  the  limitation  of  the  process  to  certain 
areas  of  the  joint.  Recovery  is  very  rarely  ideal,  namely,  with  the  func- 
tion fully  preserved.  Konig  saw  such  in  only  about  7  per  cent,  of  the 
cases.  One  usually  has  to  be  satisfied  if  the  recovery  is  accompanied 
by  impaired  motion,  possibly  a  stiff  but  still  useful  limb.  From  the 
above  description  of  the  anatomical  changes  it  is  obvious  that  in  fun- 
gous tuberculosis  as  well  as  fibrinous  hydrops  the  mobility  of  the  joint 


608 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


Fig.  3S0. 


must  suffer  as  a  result  of  shrinkage  of  the  granulations,  and  thereby  of 
the  capsule,  and  fibrinous  or  even  bony  adhesion  of  the  various  portions 
of  the  contiguous  joint-surfaces. 

The  contracture  position  is  more  frequently  the  cause  of  impairment 
than  the  partial  or  complete  stiffness  of  the  joint.  A  flexure  is  most 
frequent  after  spontaneous  recovery  as  well  as  after  conservative  treat- 
ment or  operation;  it  is  often  combined  with  a  valgus  position. 

Backward  subluxation  is  the  most  common  of  the  other  anomalous 
positions,  and  is  usually  due  to  an  improper  and  forcible  attempt  to 
correct  the  flexion  contracture.  The  head  of  the  tibia  may  slide  back- 
ward gradually  upon  the  condyles  of 
the  femur  from  the  weight  of  the 
leg  if  the  capsule,  and  especially  the 
crucial  ligaments,  are  destroyed  and 
the  knee  is  bandaged  in  flexion  upon 
a  splint  and  not  properly  supported. 
The  shrunken  posterior  portion  of 
the  capsule  holds  the  condylar  sur- 
faces of  the  tibia  firmly  against  the 
posterior  surfaces  of  the  condyles  and 
prevents  the  extension  necessary  to 
stretch  the  contracture  about  an  axis 
running  transversely,  not  through  the 
cleft  of  the  joint,  but  through  about 
the  middle  of  the  condyles.  If  for- 
cible extension  is  attempted,  the  front 
border  of  the  head  of  the  tibia  is 
pressed  against  or  even  into  the  soft 
bone  of  the  femur,  the  posterior  bor- 
der pushes  against  the  capsule,  tears 
it  off  or  tears  through  it  partially  or 
completely,  and  the  subluxation  is 
accomplished,  the  long  axis  of  the 
leg  being  parallel  to  but  behind  that 
of  the  thigh.  In  some  instances  the 
same  attempt  fractures  the  tibia  or 
the  femur  through  the  epiphysis  and 
produces  a  bayonet  deformity.  Genu 
recurvatum,  a  hyperextension  position  of  the  leg,  is  seen  very  rarely  as 
the  result  of  extensive  destruction  of  bone  or  resection;  in  the  latter 
case  due  either  to  oblique  division  of  the  bone  or  inappropriate  after- 
treatment. 

Arrested  development  occasionally  produces  functional  impairment 
in  young  subjects.  In  the  florescent  stage  of  joint-tuberculosis  in 
children  from  two  to  nine  years  old  Pels  Leusden  demonstrated  with 
the  .r-ray  a  lengthening  of  the  affected  limb  due  to  the  increased  growth 
of  the  shaft  of  the  femur.  The  majority  of  authors  are  agreed  that 
shortening  is  more  frequent  if  the  disease  is  protracted,  and  that  it  is 


Deformity  and  shortening  resulting  from  ex 
cisionof  the  knee  in  childhood.  (Whitman.) 


TUBERCULOSIS  <>!■'  THE  KNEE-JOINT.  609 

due  partly  <<>  destruction  of  the  epiphyseal  line  by  the  process  or  by 
necessary  operation  and  partly  to  disuse.  It  is  usually  from  1  to  I  \ 
inches,  hut  exceptional  eases  of  8  inches  are  known.  As  early  as  the 
florescenl  stage  the  diameter  of  the  femur  is  diminished  as  a  rule. 

Konig's  recent  statistics  of  tuberculosis  of  the  knee-joint  are  as  follows: 
Of  615  patients  treated  in  the  Gottingen  clinic  from  1875  to  IS*.)!!,  and 
watched  later,  205  (33.3  per  cent.)  died;  of  these,  SI  per  cent,  died  of 
the  various  forms  of  tuherculosis.  Of  703  patients,  only  18  succumbed 
to  infectious  diseases  or  poisoning  by  iodoform,  chloroform,  or  carbolic 
acid.  Of  those  in  which  suppuration  occurred  almost  one-half  died, 
and  of  those  without  suppuration  about  one-fourth.  Four  hundred  and 
thirty  were  well  when  these  statistics  were  collected. 

Treatment. — The  question  as  to  conservative  or  operative  treatment 
of  tuberculosis  of  the  knee-joint  is  still  unsettled.  After  a  discus- 
sion lasting  through  two  decades  a  uniform  opinion  is  hardly  to  be 
expected  as  the  material  of  individual  surgeons,  the  hygienic  surround- 
ings, and  the  consequent  results  of  treatment  vary  too  much.  The 
period  of  almost  purely  operative  treatment  following  the  introduction 
of  antisepsis  has  been  followed  by  one  or  more  conservative  methods, 
the  latter  being  superseded  at  the  present  time  by  almost  ultracon- 
servatism  in  not  a  few  places.  It  is  only  in  a  few  of  the  cases,  namely, 
those  in  which  the  age  and  poor  general  condition  of  the  patient,  the 
high  fever  due  to  mixed  infection,  and  severe  destruction  of  the  joint, 
etc.,  are  counterindications,  that  conservative  treatment  is  without 
prospect  and  resection  or  amputation  is  to  be  considered.  In  the  large 
majority  of  cases  conservative  measures  will  be  adopted,  varying  some- 
what according  to  the  view  of  the  individual  surgeon,  although  very 
often  operation  will  be  necessary  later. 

The  most  important  and  effectual  element  of  conservative  treatment 
is  absolute  rest  of  the  limb  with  the  knee  extended.  A  flexure  or  an 
abduction  contracture  is  overcome  if  slight  and  recent  by  manual  correc- 
tion under  anaesthesia:  By  gradual  steady  traction  and  pressure  the  leg  is 
extended  and  adducted,  avoiding  extension  in  the  improper  axis  described 
above.  A  plaster-splint  is  then  applied.  If  the  straightening  is  not  com- 
plete, it  is  repeated  in  two  to  three  weeks,  and  again  later  if  necessary. 

Continuous  extension  is  usually  preferable  if  the  correction  is  diffi- 
cult, the  desired  result  being  obtained  in  two  or  three  weeks;  in  the 
case  of  children  10  to  25  pounds  being  used,  and  in  adults,  if  the  process 
is  not  too  old,  20  to  35  pounds.  Any  remaining  flexion  or  abduction  is 
generally  overcome  easily  and  without  danger  under  anaesthesia.  The 
technic  will  be  found  under  contractures.  Many  prefer  to  continue 
the  extension  later  to  separate  the  joint-surfaces,  the  favorable  influence 
of  which  has  been  demonstrated  beyond  question.  It  seems  to  the 
author,  however,  that  once  having  corrected  the  position  the  immo- 
bilization assured  by  a  circular  splint  is  more  important  than  the 
"distraction"  of  the  articular  surfaces. 

A  portable  plaster-splint  is  preferable,  to  the  author's  mind,  on 
account  of  its  simplicity  and  utility  in  clinical  work.  It  is  applied  from 
Vol.  III.— 39 


610 


DISEASES  IS  AXB  ABOUT  THE  KXEE  JOIXT. 


the  foot  to  the  groin  over  a  muslin  or  flannel  bandage,  fitting  snugly 
but  without  constricting  or  exerting  unequal  pressure.  If  applied  im- 
mediately after  forcibly  extending  the  knee  under  anaesthesia,  the  limb 
should  be  elevated  for  twenty-four  hours  and  kept  under  observation. 
If  the  foot  becomes  oedematous  and  cyanotic,  the  splint  should  be 
removed,  the  limb  padded  lightly  with  cotton,  and  a  new  splint  put  on. 
Moderate  swelling  subsides  usually  in  twenty-four  to  forty-eight  hours. 
The  child  may  then  be  sent  home.     The  splint  is  renewed  in  three  or 


Fig.  381. 


Fig.  382. 


Plaster-of-Paris  splint  with  Lorenz'  stilt. 


The  Thomas  knee-brace.   (Whitman.) 


four  and  again  in  six  to  eight  weeks,  the  child  meanwhile  returning  for 
clinical  treatment  and  provided  with  the  necessary  nourishing  diet, 
fresh  air,  cleanliness,  etc.  The  ankle  should  be  included  in  the  first 
splint;  later  it  may  be  left  out  to  prevent  stiffness.  If  the  patient  is 
allowed  to  be  about,  v.  Brims'  portable  splint,  put  on  over  the  plaster, 
is  very  useful,  as  it  takes  the  weight  off  the  knee,  the  sound  foot  being 
raised  by  a  sole  and  heel  of  the  proper  thickness.  Lorenz  obtains  the 
same  support  by  incorporating  an  iron  foot-brace  in  the  plaster.     (Fig. 


TUBERCULOSIS  OF  THE  KNEE  JOINT.  611 

381.)  The  two  side-pieces  are  usually  carried  up  to  the  pelvis  against 
a  thick  rubber  perineal  ring.  The  splinl  is  then  like  the  Thomas  - j >1  int, 
except  that  it  is  math'  immovable  by  the  plaster  and  thus  disencumbers 
the  knee  in  walking.  Many  prefer  the  sheath  splints,  but  their  expense 
makes  them  impossible  for  poor  patients. 

The  author  does  not  begin  the  ambulatory  treatment  until  the  second 
or  third  splint  has  been  applied  and  the  swelling  and  pain  in  the  joint 
have  subsided.  The  favorable  influence  of  the  ambulant  treatment 
upon  the  general  condition  is  greatly  overestimated;  ambulant  treat- 
ment is  counterindicated  as  long  as  the  existence  of  fever,  not  neces- 
sarily high,  points  to  florescence  or,  with  more  probability,  to  suppuration. 
The  immobilization  in  plaster  is  continued  till  all  swelling  and  tender- 
ness have  disappeared,  after  which  it  is  well  to  have  a  removable  support- 
ing apparatus  worn  for  a  month  or  more,  leaving  the  foot  free.  Such 
an  apparatus  is  easily  made  of  gauze  and  silicate.  The  resulting  stiff- 
ness of  the  joint  and  atrophy  of  the  muscles  can  be  overcome  gradually 
and  often  very  completely  if  the  adhesions  in  the  joint  are  slight,  and 
therefore  do  not  require  energetic  treatment  except  massage  and  the 
wearing  of  an  appropriate  apparatus.  Forcible  mobilization  is  always 
liable  to  start  up  the  tuberculous  process.  It  may  be  years  before 
motion  is  fully  restored. 

The  injection  of  iodoform  emulsion  is  combined  advantageously  with 
immobilization.  Although  its  favorable  influence  is  not  constant,  the 
results  are  often  striking;  in  hydrops  the  obstinate  effusion  may  disappear 
rapidly  and  permanently.  In  the  case  of  typical  fungus  it  often  pays  to 
try  the  injection  unless  operation  is  urgent.  Improvement  occasionally 
follows  the  first  injection;  if  none  occurs  after  the  fourth  or  fifth,  further 
attempts  are  useless.  Injection  is  painful,  but  may  be  done  without 
anaesthesia.  The  pain  usually  lasts  for  about  a  day,  and  is  occasionally 
followed  by  a  greater  effusion  and  slight  temperature,  both  of  which 
subside  rapidly  in  the  absence  of  infection.  A  fair-sized  aspirating- 
needle  is  preferable,  sterilized  by  boiling.  The  puncture  is  made  at  the 
outer  side  of  the  upper  recess  or  at  the  appropriate  point  if  the  swelling 
is  circumscribed.  The  fluid  in  the  joint  is  withdrawn  and  5  to  10  c.c.  of 
10  per  cent,  iodoform-glyeerin  or  oil  is  injected,  according  to  the  age  of 
the  patient,  and  spread  through  the  joint  by  turning  the  needle  in  dif- 
ferent directions  and  then  moving  the  joint  slightly.  It  is  not  advisable 
to  inject  more  than  10  c.c.  at  first  until  the  toleration  of  the  individual 
is  determined.  The  wound  is  sealed  with  iodoform  collodion.  The 
injection  is  repeated  at  intervals  of  ten  to  fourteen  days  after  aspirating; 
iodoform  from  the  previous  injection  is  often  withdrawn.  In  suppurat- 
ing cases,  if  the  action  is  favorable  the  effusion  becomes  more  greenish 
and  serous  after  the  second  injection.  If  a  plaster-splint  is  applied 
immediately  after  injecting,  a  thick  pad  of  cotton  should  be  placed 
over  the  joint  to  allow  for  the  swelling.  Instead  of  iodoform  Konig 
uses  a  5  per  cent,  carbolic  acid  solution  after  washing  out  the  joint 
with  a  2  per  cent,  solution  of  the  same.  He  was  successful  thus  where 
iodoform  had  failed;  to  be  sure,  the  reverse  was  also  true. 


612 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOIST. 


Fig.  383. 


Biers  congcstion-hyperosmia  with  or  without  injection  of  iodoform  has 
been  recommended  by  many  recently.  The  rubber  band  is  applied  on 
the  thigh  for  several  hours  or  a  day,  according  as  it  is  well  borne,  and 
removed  at  night;  it  should  only  check  the  venous  return.  The  skin 
below  the  bandage  becomes  cyanotic  and  swollen;  the  pain  may  be 
more  or  less  severe,  but  soon  becomes  tolerable.     Mikulicz  cites  as  the 

special  advantage  of  the  treatment  that  the 
pain  subsides  rapidly  in  cases  of  very  sensi- 
tive joints.  Large  abscesses  are  a  counterin- 
dication;  those  forming  during  the  treatment 
should  be  aspirated  and  injected  with  iodo- 
form. The  results  are  very  uncertain,  great 
improvement  being  contrasted  with  failures  or 
even  exacerbation.  The  statistics  are  few. 
The  method  should  be  only  used  under  con- 
stant observation. 

Partial  operations,  such  as  incision  of  ab- 
scesses, splitting  of  fistulas,  exposure  and 
cleansing  of  extra-articular  osseous  foci,  or 
even  free  incision  of  cold  abscesses  about  the 
joint,  are  less  dangerous  since  the  introduc- 
tion of  antisepsis,  and  are  indicated  if  repeated 
aspiration  and  injection  of  iodoform  fail,  or 
perforation  outward  is  imminent,  or  the  exist- 
ing fever  is  due  to  the  cold  abscess  and  not 
to  the  process  in  the  joint.  After  free  incision 
of  the  abscess  the  lining  membrane  is  removed 
with  a  sharp  spoon,  the  cavity  packed  with 
iodoform  gauze,  and  the  wound  left  open,  in 
the  case  of  large  abscesses,  or  partially  closed. 
Sometimes  the  abscesses  heal  entirely,  then 
again  a  fistula  persists  for  a  long  time.  Extra- 
articular osseous  foci  are  cleaned  out  at  the 
same  time  if  found.  The  expectations  for- 
merly aroused  by  this  operation  were  unful- 
filled because  in  the  majority  of  cases  the 
joint  was  already  involved,  or  was  opened  in- 
The  application  of  passive  con-  tentionally  or  otherwise  at  the  time  of  opera- 

gestion.   A,  the  alternate  point  for       .  ,  J  ,  .    ,.      .     „  ,         XT  , 

the  application  of  the  bandage,  in   tion   and  the  synoviahs  infected.     Neverthe- 
order  to  avoid  atrophy  from  con-   \ess  the  procedure   is  an  ideal  one  for  foci  in 

tore's    B'  Th<?  rUbbeF    the  head  °f   tlie  tibia   °r  tllOSe    in    the  ePic011- 

dyles  of  the  femur  perforating  laterally.  The 
incision  should  be  free  and  the  bone  chiselled  out  thoroughly  and  be- 
yond the  limits  of  the  focus.  If  the  joint  is  opened  unintentionally, 
as  is  often  unavoidable,  but  no  diseased  tissue  has  been  pushed  in 
through  the  wound  in  the  capsule,  the  latter  may  be  sutured  with  fine 
catgut;  if  a  circumscribed  portion  of  the  capsule  is  found  to  be  in- 
volved, it  may  be  excised.     The  wound  is  packed  lightly  with  iodo- 


TUBERCULOSIS  OF  THE  KNEE  JOINT.  613 

form  gauze,  a  dressing  applied,  and  the  limb  immobilized  in  a  strip 
or  plaster-splint. 

Arthrectomy  is  supposed  to  accomplish  for  disease  of  the  joint  itself 
all  thai  the  above  operations  promised  for  single  osseous  foci.  By 
excising  all  diseased  tissue,  especially  the  entire  synovialis,  and  pre- 
serving all  healthy  tissue,  a  rapid  and  certain  recovery  was  hoped  for 
without  the  serious  disadvantages  of  the  shortening  and  functional  loss 
of  typical  resection.  The  operation  was  therefore  recommended  as 
the  one  of  choice  in  the  early  stage.  But  the  expectation  was  only 
partially  realized  as  the  resulting  partial  mobility  aided  the  develop- 
ment of  a  flexion  contracture  and  diminished  the  strength  of  the  joint, 
although  the  mortality  of  the  operation  was  slight  and  recovery  rapid 
if  all  diseased  tissue  was  removed. 

In  150  arthrectomies,  largely  in  children,  Konig  only  experienced  3 
deaths;  of  133  of  these  watched  later,  23  died,  27  remained  entirely 
unhealed;  of  the  94  that  recovered,  shortening  was  absent  in  27,  slight 
in  40,  moderate  in  20,  and  very  marked  in  7.  In  view  of  these  expe- 
riences, which  correspond  fairly  well  with  those  of  other  surgeons,  the 
field  of  arthrectomy  has  been  limited.  Early  operation  has  been 
almost  entirely  abandoned.  The  method  is  used  therefore  only  where 
conservative  treatment  is  without  prospect  or  has  failed  and  resection 
is  relinquished  for  fear  of  checking  the  growth.  The  frequent  deformity 
following  arthrectomy  is  due  to  the  fibrous  or  cartilaginous  synostosis 
forming,  usually  with  a  slight  flexure;  the  latter  is  increased  by  the 
weight  of  the  body,  especially  if  the  extensors  are  weak.  In  arthrec- 
tomy, as  in  resection,  where  the  ligaments,  especially  the  crucial  liga- 
ments, have  to  be  sacrificed,  as  is  usually  the  case,  a  movable  joint  is 
impossible,  therefore  the  author  fixes  the  leg  and  thigh  firmly  in  exten- 
sion, and  insures  this  position  by  protracted  application  of  a  splint  or 
apparatus.  For  the  same  reason  exposure  of  the  joint  through  a  trans- 
verse incision  is  preferable  rather  than  through  one  or  two  longitudinal 
incisions,  the  essential  being  the  removal  of  all  diseased  tissues.  The 
transverse  incision  gives  a  better  view  of  the  joint,  especially  the  posterior 
part;  as  bony  ankylosis  is  desired,  there  is  no  disadvantage  in  dividing 
and  suturing  the  extensors. 

The  operation  is  performed  under  application  of  the  Esmarch  after 
any  existing  contracture  has  been  diminished  or  overcome  by  appropri- 
ate extension  for  several  days.  The  incision,  transverse  between  the 
epicondyles,  crosses  the  patella,  as  made  by  v.  Yolkmann,  or  curves  up- 
ward through  the  quadriceps  tendon  or  downward  through  the  patellar 
ligament.  The  soft  parts  are  retracted,  and  the  capsule  dissected  off 
from  above  down  to  the  menisci.  The  upper  recess  is  thus  removed  en 
masse  from  the  femur.  Two  lateral  longitudinal  incisions  may  also  be 
made  in  the  fascia  lata  1  to  H  inches  from  the  patella  so  as  to  turn  up  the 
soft  parts.  The  lateral  ligaments  are  then  divided  at  their  attachments, 
also  the  crucial  ligaments,  keeping  close  to  the  bone.  The  posterior  wall 
of  the  capsule  is  then  excised  carefully.  The  attempt  to  preserve  the 
crucial  ligaments  is  usually  followed  by  recurrence,  and  should  therefore 


614  DISEASES  IN  AXD  ABOUT  THE  KNEE-JOINT. 

be  limited  to  circumscribed  disease  of  the  synovialis.  All  tuberculous 
granulations  are  removed  from  the  cartilage  as  well  as  all  diseased 
bone  and  sequestra;  caries  or  granulations  deep  in  the  bone  are  scraped 
out  thoroughly  with  a  sharp  spoon.  This  often  means  excision  of  a  large 
part  of  or  the  entire  epiphyseal  cartilage.  Any  visible  divided  arteries 
are  tied.  The  author  then  proceeds,  according  to  v.  Bergmann,  to  fill 
the  cavitv  and  all  recesses  with  iodoform  gauze,  suturing  the  wound, 
usually  without  drainage,  after  the  third  or  fourth  day.  The  limb  is 
immobilized  in  a  tin-splint.  After  secondary  suture  and  exact  coapta- 
tion of  the  joint-surfaces  the  limb  is  enveloped,  extended,  in  a  plaster 
splint  reaching  from  the  mid-tarsus  to  the  groin.  If  recovery  is  uninter- 
rupted, it  is  left  on  three  weeks.  Periarticular  abscesses  are  exposed 
freely  by  longitudinal  incisions  and  scraped  out  and  packed,  the  large 
vessels  and  nerves  being  avoided.  To  protect  the  extensors,  Konig 
makes  two  lateral  longitudinal  incisions  beginning  at  the  -pine  of  the 
tibia  and  curving  upward  toward  the  lateral  ligaments  to  end  at  either 
side  of  the  quadriceps  tendon. 

Resection  is  indicated  in  all  cases  in  which  it  is  desirable  to  remove  all 
tuberculous  foci  and  obtain  bony  union  between  the  surfaces  of  the 
resected  stumps.  As  the  removal  of  the  epiphyseal  cartilage  checks 
the  growth  of  the  bone,  the  operation  is  not  employed  by  many  sur- 
geons before  the  fifteenth  year.  In  adults  it  is  the  ideal  operation  if  con- 
servative methods  fail  and  amputation  is  not  indicated.  Of  Konig's 
300  cases,  the  result  was  poor  in  75,  among  these  there  were  29  deaths 
during  treatment,  23  secondary  amputations,  2  not  improved,  and  21 
deaths  later  among  the  non-recovered;  among  222  with  a  good  result 
188  were  discharged  cured,  31  were  cured  later,  and  slight  fistulas 
remained  in  3.  The  prognosis  became  less  favorable  with  increasing 
age. 

In  resecting,  the  extensors  do  not  have  to  be  so  carefully  protected,  so 
that  any  one  of  the  three  transverse  incisions  mentioned  may  be  used; 
if  the  patella  is  involved,  it  is  removed,  otherwise  it  increases  the  solidity 
of  the  ankylosis.  After  opening  the  joint  and  dividing  the  lateral  liga- 
ments the  synovialis  is  removed  as  in  arthrectomy,  the  condyles  of  the 
femur  and  tuberosities  of  the  tibia  are  freed  of  attachments,  protruded, 
and  sawed  off  transversely  and  somewhat  obliquely  backward  to  give  a 
slight  flexion  position  of  about  175  degrees.  If  one  condyle  is  affected 
more  than  the  other,  the  surface  may  be  made  oblique  from  side  to  side 
and  the  tibia  correspondingly  oblique  in  the  other  direction.  The 
posterior  part  of  the  capsule  is  then  excised,  all  foci  in  the  bone  scraped 
out  with  a  sharp  spoon  or  chiselled  otit,  the  stumps  approximated,  two 
short  drainage-tubes  inserted  at  the  posterior  angles  of  the  wound,  and 
two  longer  tubes  inserted  in  incisions  at  either  side  of  the  quadriceps 
tendon,  and  the  wound  closed  after  uniting  the  extensors  with  deep 
sutures.  Xo  special  sutures  or  nails  are  necessary  for  the  stumps. 
With  the  limb  held  vertically,  a  dressing  is  applied  from  the  ankle  to 
above  the  middle  of  the  thigh,  the  Esmarch  removed,  and  a  circular 
plaster-splint  applied.      The  dressing  should  exert  moderate  pressure 


DISEASE  OF  THE  KNEE-JOINT  IN  HEMOPHILIA.  615 

over  the  knee  to  prevent  secondary  bleeding;  the  limb  is  elevated  verti- 
cally for  about  twenty-four  hours.  If  recovery  is  uneventful,  the  splint 
is  left  on  for  three  weeks.  In  adults  the  shortening  is  only  that  entailed 
by  the  hone  removed,  usually  from  \\  to  2\  inches;  if  growth  is  not 
complete,  it  is  more,  exceptionally  even  8  inches.  A  flexion  contracture 
is  possible  if  the  ankylosis  is  not  bony  but  cartilaginous  or  fibrous,  car- 
tilaginous union  occurring  in  younger  patients  if  the  cartilage  is  pre- 
set ved,  fibrous  if  cavities  are  chiselled  out  in  the  bone  or  suppuration 
occurs. 

The  indications  for  the  preceding  operations  may  be  summarized  as 
follows:  the  choice  depends  upon  the  age  of  the  patient,  general  con- 
dition, social  position,  duration  of  the  disease,  and  the  degree  of  destruc- 
tion of  the  joint.  If  the  patient  is  young,  the  general  strength  and 
nourishment  good,  the  environment  favorable,  and  the  process  seen 
early,  the  surgeon  should  try  conservative  treatment,  immobilization  in 
a  plaster-splint  after  correcting  the  position,  and  injection  of  iodoform, 
and  with  the  reverse  conditions  operate  as  soon  as  possible.  Hydrops 
and  dry  fungus  without  abscesses  or  fistulas,  and  in  young  and  other- 
wise healthy  patients,  are  especially  suitable  for  conservative  treatment. 
Purely  extracapsular  tuberculous  foci  require  early  removal.  In  cases  of 
suppuration  of  the  joint  or  fistulas  with  continuous  moderate  fever,  the 
conservative  treatment  should  not  be  prolonged,  but  operation  per- 
formed; in  children  arthrectomy,  in  adults  resection;  the  same  applies 
to  marked  abduction  or  flexion  contractures  if  they  cannot  be  corrected 
sufficiently  under  anaesthesia  or  by  extension. 

General  weakness,  the  existence  of  multiple  foci,  especially  advanced 
phthisis  or  severe  amyloid  degeneration,  old  age,  and  progressive  infiltra- 
tion of  the  shaft,  are  indications  for  amputation. 


DISEASE  OF  THE  KNEE-JOINT  IN  HAEMOPHILIA. 

The  clinical  picture  of  the  knee-joint  affection  occurring  with  haemo- 
philia, although  rare,  is  very  similar  to  that  of  tuberculosis.  The 
ha?marthrosis  occurs  after  slight  trauma  or  suddenly  and  spontaneously 
during  the  night  without  pain,  fever  or  further  functional  disturbance, 
presenting  a  more  or  less  characteristic  distention  of  the  upper  recess, 
fluctuation  and  ballottement  of  the  patella.  The  hemorrhagic  character 
of  the  effusion  is  at  least  suspected  from  the  fact  that  the  patient  is 
a  bleeder  or  has  such  an  heredity.  The  bluish  spots  appearing  in  the 
skin  over  the  joint  in  a  few  days  often  facilitate  the  diagnosis.  One  or 
more  joints  may  be  affected  at  the  same  time. 

The  effusion  may  be  resorbed  entirely,  especially  if  the  joint  is  pro- 
tected. If  repeated,  the  disturbance  may  be  more  severe.  The  fibrin 
is  deposited  on  the  same  parts  of  the  synovialis  and  cartilage  as  in 
tuberculosis  and  becomes  organized;  this  is  the  second  stage  of  panar- 
thritis described  by  Konig.  On  opening  the  joint  bloody  serum  is  dis- 
charged and  the  villi  are  seen  to  be  increased,  the  cartilage  is  brownish 


616 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


or  grayish,  dull,  and  pitted,  the  bone  being  exposed  in  places.  The 
further  organization  of  the  fibrin  produces  adhesions  between  the 
joint-surfaces  and  impaired  motion.  The  third  stage  with  contracture 
in  flexion  and  abduction  follows.  (Fig.  384.)  Even  by  the  experienced 
the  affection  may  be  mistaken  in  the  first  stage  for  a  tuberculous  hydrops, 
in  the  second  for  a  typical  fungus.  Formerly  it  was  confused  with 
gout,  rheumatism,  or  tumor  albus,  even  when  it  was  known  that  the 
patient  was  a  bleeder.  The  youth  of  the  patient,  the  pallor,  the  rapid 
effusion  with  or  without  slight  cause,  the  absence  of  discomfort  at  the 
outset,   the  simultaneous  or  subsequent   involvement  of  other  joints, 

Fig.  384. 


Hsemarthrosis  of  both  knee?  in  a  "bleeder."  with  contracture  at  an  acute  angle,      (v.  Brans.) 


the  ecchymosis,  and  the  history  of  former  attacks  with  rapid  recovery 
without  suppuration  or  impaired  function,  all  point  to  a  haemar- 
throsis. 

Prognosis. — The  prognosis,  disregarding  the  inability  to  combat  the 
disease  and  prevent  recurrence,  is  unfavorable  on  account  of  the  partial 
or  complete  stiffness  and  contracture  resulting  in  the  course  of  time 
from  repeated  hemorrhages. 

Treatment. — In  the  early  stage  slight  pressure  should  be  applied 
with  immobilization;  active  massage  or  forced  movements  should  be 
avoided.  Later,  careful  extension  of  the  flexed  knee  and  the  support 
given  by  a  plaster-splint  or  well-fitting  sheath  splint  are  often  beneficial. 
Aspiration  and  irrigation  with  carbolic  acid  are  the  only  operations  to  be 


SYPHILIS  OF  THE  KNEE  JOINT.  617 

considered;  they  often  aid  resorption.  Incision  or  other  operations  are 
counterindicated  on  account  of  the  danger  of  immediate  or  secondary 
hemorrhage. 

SYPHILIS  OF  THE  KNEE-JOINT. 

Syphilis  affects  the  knee  more  frequently  than  any  other  joint.  Dur- 
ing the  secondary  stage  there  may  be  a  serous  effusion  in  one  or  both 
knees  or  in  several  joints.  The  acute  synovitis  does  not  differ  essen- 
tially from  that  in  the  other  infectious  diseases;  suppuration  is  apparently 
very  rare.  The  effusion  disappears  under  specific  treatment  with 
immobilization  and  compression. 

In  the  tertiary  stage  the  lesion  is  a  chondro-arthritis  (Rasch) ;  it  is 
questionable  whether  a  pure  synovitis  ever  occurs.  In  specimens  the 
cartilage  is  found  to  be  frayed,  ulcerated,  or  furrowed  by  cicatricial 
depressions  in  the  middle  of  the  condyles  or  of  the  patella,  less  fre- 
quently at  the  edges,  the  remains  of  a  healed  gumma  (Virchow) ;  the 
underlying  bone  may  be  diseased  or  intact.  The  synovialis  shows 
diffuse  or  nodular  thickening,  the  nodules  being  bluish-red,  grayish- 
white  in  the  centre,  oval  or  round,  softly  elastic,  caseous  or  chalky,  and 
at  the  edges  densely  fibrous  or  hard.  The  villi  are  greatly  increased. 
The  periosteum  or  the  spongiosa  may  be  filled  with  gummata,  which 
may  soften  and  perforate  into  the  joint.  The  effusion  is  cloudy  serous 
or  rarely  purulent  if  a  suppurating  gumma  has  perforated  into  the  joint. 

The  affection  is  very  rarely  acute  or  subacute,  but  usually  chronic, 
analogous  to  tuberculosis  and  with  very  similar  symptoms,  namely,  the 
form  of  the  swelling,  the  effusion,  the  contour  of  the  capsule,  the  tend- 
ency to  contracture,  especially  in  abduction.  It  is  distinguished  from 
tuberculosis,  aside  from  the  rarity  of  suppuration,  by  the  striking  tense- 
ness of  the  swelling,  by  the  relatively  slight  functional  disturbance 
compared  to  the  latter,  and  by  the  severe  pain.  The  pain  is  frequently 
more  intense  at  night.  The  diagnosis  is  facilitated  by  the  history  of 
previous  specific  infection  or  evidence  of  the  same  elsewhere,  the  palpa- 
tion of  a  gumma  in  the  capsule  or  in  the  ends  of  the  femur  or  tibia,  and 
the  absence  of  a  tuberculous  heredity  or  habitus.  In  doubtful  cases 
the  treatment,  energetic  exhibition  of  potassium  iodide,  immobilization, 
and  light  compression,  is  conclusive  and  usually  brings  about  a  rapid 
recovery. 

In  hereditary  syphilis  one  or  both  knee-joints  are  rather  frequently 
affected.  A  rapid  bilateral  effusion  in  young  children  should  always 
arouse  a  suspicion  of  syphilis.  Robinson  distinguishes:  1.  Specific 
epiphysitis  with  or  without  spontaneous  separation  of  the  epiphysis. 
2.  Symmetrical  effusion  occurring  rapidly  and  without  pain,  usually 
in  the  eighth  to  the  fifteenth  year.  3.  Ostitis:  (a)  with  simple  effusion 
or  (b)  with  gummatous  infiltration  of  the  synovialis  and  effusion. 
4.  Primary  gummatous  synovitis. 

Suppuration  is  much  more  frequent  in  acquired  than  hereditary 
syphilis.     Among  other  symptoms  of  general  infection  should  be  men- 


618  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

tioned  interstitial  keratitis,  a  frequent  complication  which  occasionally 
appears  after  the  joint-affection. 

Treatment. — In  the  inherited  as  well  as  acquired  affection  of  the 
joint  the  treatment  consists,  in  addition  to  specific  measures,  in  proper 
nourishment,  care  of  the  skin,  calomel  in  small  doses,  or,  according  to 
Bosse,  preferably  potassium  iodide.  Giiterbock  recommends  sublimate 
baths  (8  grains  to  the  bath)  for  young  children.  Appropriate  local 
treatment  is  also  necessary. 


CHRONIC  RHEUMATISM  OF  THE  KNEE-JOINT. 

Formerly  belonging  exclusively  to  internal  medicine,  chronic  artic- 
ular rheumatism,  especially  of  the  knee,  has  recently  claimed  the 
attention  of  surgeons  and  given  rise  to  operation.  Although  commonly 
a  local  manifestation  of  general  muscular  or  articular  rheumatism,  it 
not  infrequently  occurs  alone,  at  least  it  is  not  possible  to  explain  certain 
cases  of  isolated  gonarthritis  otherwise  than  as  rheumatic.  Further,  it 
is  not  positively  known  whether  or  not  chronic  rheumatism  always 
results  from  the  acute  process — that  is,  from  the  same  causes.  The 
significance  of  a  peculiar  plump  bacillus,  similar  in  many  respects  to 
Bacillus  prodigiosus,  found  by  Schiiller  in  the  synovialis  and  hyper- 
trophied  villi  of  inflamed  joints,  and  confirmed  by  Bannatyne  and 
Wohlmann,  still  requires  confirmation.  All  the  so-called  causes  of 
cold,  damp  dwellings,  cold  damp  weather,  etc.,  favor  the  production 
of  the  affection.  Although  it  occurs  chiefly  in  the  poor  living  under 
unfavorable  circumstances,  the  wealthier  classes  are  not  immune.  The 
anatomical  changes  are  often  slight;  repeated  or  prolonged  attacks 
are  regularly  followed  by  growth  of  the  villi,  formation  and  con- 
traction of  fibrous  tissue,  as  in  the  capsule,  a  fraying  out  and  partial 
erosion  of  the  cartilage,  adhesions  between  the  folds  of  the  capsule  and 
finally  between  the  joint-surfaces.  The  effusion  is  usually  slight,  often 
absent,  especially  if  fibrous  adhesions  form  later.  In  some  instances 
it  is  more  profuse  and  either  serous  or  flocculent. 

Symptoms. — The  symptoms  correspond  to  the  anatomical  changes. 
They  may  be  absent  at  the  onset  or  for  a  long  while.  The  patient  com- 
plains of  tearing  pains  in  the  knees  of  varying  intensity,  and  unaccom- 
panied by  swelling,  or  tenderness  or  much  limitation  of  passive  motion; 
extensive  active  motion  is  usually  avoided;  later,  passive  motion  is 
somewhat  limited  and  crepitus  can  be  felt  and  heard,  often  even  by  the 
patient.  Although  crepitus  can  often  be  elicited  in  healthy  people, 
and  is  therefore  not  entirely  pathognomonic,  still  it  has  some  diagnostic 
significance  as  soon  as  it  exceeds  a  certain  intensity,  is  only  found  in  the 
one  joint,  and  varies  with  the  other  symptoms — that  is,  disappearing 
partially  or  completely  with  improvement,  and  the  reverse.  Tempo- 
rarily, especially  after  long  use,  the  joint  may  be  swollen  and  give 
evidence  of  moderate  effusion;  the  latter  may  last  for  a  few  hours,  the 
knee  being  swollen  at  night  and  normal  in  the  morning,  or  persist  for 


CHRONIC  DEFORMING  INFLAMMATION  OF  THE  KNEE-JOINT.    61(J 

days  or  weeks  and  remain  stationary  in  neglected  cases.  In  the  ad- 
vanced stage  there  may  be  partial  or  pronounced  stiffness  with  moderate 
flexion. 

As  the  name  indicates,  the  affection  is  chronic  and  difficult  to  cure. 
It  usually  occurs  by  attacks,  with  periods  of  exacerbation  and  of  com- 
plete or  partial  freedom.  There  is  always  a  great  tendency  to  recur- 
rence. Although  recovery  is  complete  in  some  cases,  in  a  large  major- 
ity the  advance  is  slow  but  gradual  to  final  stiffness. 

Treatment. — The  same  drugs  are  much  used  as  in  acute  articular 
rheumatism,  namely,  the  various  preparations  of  salicylic  acid,  anti- 
pyrin,  piperazin,  potassium  iodide,  arsenic,  etc.,  but  usually  only  with 
slight  effect.  Warm  full  baths,  steam  baths,  mud  baths,  and  hot  sand 
baths  are  more  useful.  The  natural  hot  baths  of  Teplitz,  Wildbad, 
(iastein,  Wiesbaden,  and  Baden-Baden  enjoy  a  wide  and  not  unde- 
served reputation,  but  are  ineffectual  often  enough.  Locally  wet  com- 
presses, mud,  iodine,  ichthyol,  etc.,  are  applied  with  benefit.  Lately 
the  hot-air  treatment  has  given  excellent  results.  The  author  has  not 
been  able  to  verify  the  favorable  action  of  massage  reported  by  others. 
After  the  pain  has  subsided,  combined  with  careful  gymnastics  it  may 
prevent  or  help  to  overcome  stiffness.  Complete  immobilization  in  a 
plaster-splint  and  overuse  of  the  limb  are  equally  inadvisable.  The 
slight  discomfort  at  the  outset  is  often  disregarded  by  energetic  people, 
but  usually  with  the  effect  of  bringing  on  an  exacerbation,  so  that  at  this 
stage,  when  the  prospect  of  recovery  is  best,  the  patient  should  be 
urged  to  protect  the  limb  with  the  greatest  care  and  to  rest.  Careful 
movement  of  the  knee  while  in  bed  or  upon  a  couch  is  not  only  permis- 
sible, but  advisable  to  prevent  stiffness. 


CHRONIC  DEFORMING  INFLAMMATION  OF  THE  KNEE-JOINT. 

It  is  difficult  to  draw  a  sharp  line  between  chronic  articular  rheuma- 
tism and  chronic  deforming  inflammation  of  the  joint.  Nevertheless, 
from  our  present  knowledge  one  is  not  justified  in  classifying  the  two 
together,  as  the  deforming  proliferation  of  cartilage  and  bone  character- 
istic of  gout  is  not  peculiar  to  rheumatism.  The  knee  is  frequently  the 
seat  of  arthritis  deformans  alone  or  simultaneous  with  other  joints, 
the  predisposing  causes  being  cold,  previous  rheumatism,  unfavorable 
hygienic  surroundings;  heredity  also  apparently  plays  some  part.  The 
affection  is  more  common  between  the  fortieth  and  fiftieth  year,  rare 
under  thirty.  The  monarticular  form  develops  chiefly  after  trauma  of 
the  joint,  severe  sprains,  fracture  of  one  or  both  condyles  or  tuberosities, 
avulsion  or  contusion  of  a  meniscus,  etc. 

Changes  are  found  in  all  parts  of  the  joint.  The  villi  grow  out  in  the 
form  of  long  filaments,  thick  polypoid,  or  dendritic  masses,  either  pale  or 
deep  red,  soft  or  firm,  often  projecting  well  into  the  joint  cavity;  they 
consist  of  vascular  connective  tissue  and  fat,  being  termed  lipoma  arbo- 
rescens  if  the  fat  predominates  and  the  growths  are  large.     Cartilage- 


620  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

cells  are  often  found  in  the  villi,  which  latter  may  calcify  or  ossify. 
The  capsule  is  thickened  and  frequently  contains  thick  plates  of  bone. 
The  hyaline  substance  of  the  cartilage  of  the  joint  becomes  fibrous;  the 
perichondrium  proliferates,  chiefly  along  the  edges  of  the  condyles,  into 
irregular  cartilaginous  tumors,  pushing  the  capsule  before  them  or 
growing  beyond  the  normal  line  of  the  cartilage;  they  remain  partly 
cartilaginous  or  are  invaded  by  vessels  from  the  spongiosa  and  become 
ossified.  In  the  knee  especially  the  tumors  are  sometimes  unusually 
large.  The  cartilage  disappears  and  the  surfaces  of  the  tibia  and  femur 
become  polished,  less  so  of  the  patella,  giving  them  a  broader  and  flatter 
appearance.  In  the  bone  under  the  cartilage  one  often  finds  hyaline 
enchondromata  with  cysts  and  small  foci  of  compact  connective  tissue. 
The  effusion  is  usually  slight,  yellowish  or  reddish,  slightly  cloudy,  rich 
in  fibrin.  Free  bodies  of  various  sizes  and  shapes  are  formed  from 
fibrin  and  detached  villi.  Large  numbers  of  free  foodies  are  found, 
especially  in  the  knee-joint  deformed  by  gout.  In  the  traumatic  mon- 
articular form  free  fragments  of  the  joint-surfaces  are  often  seen.  The 
effusion  is  sometimes  very  great. 

Symptoms. — At  the  onset  the  symptoms  are  indefinite:  The  patient 
usually  complains  of  slight,  rarely  severe  darting  pain,  radiating  down 
the  leg  from  the  knee;  of  fatigue  on  slight  exertion;  occasionally  of  slight 
swelling  of  the  joint.  When  the  pathological  changes  become  palpable, 
soft  or  harsh  crepitus,  "snowball-crunching,"  or  even  the  crepitus  of  a 
bag  full  of  peas,  may  be  felt.  Larger  free  bodies  can  sometimes  be 
seized  and  pushed  about.  Later  the  cartilaginous  growth  can  be  felt 
along  the  edge  of  the  condyles  and  the  deformity  seen  and  verified  by 
comparison  with  the  other  knee,  the  femur  or  tibia  being  broadened. 
Greater  deformity  produces  a  genu  valgum  or  varum.  Extension  and 
flexion  are  limited,  although  retained  much  longer  than  in  the  other 
chronic  affections  of  the  joint,  especially  tuberculosis. 

Usually  the  stiffness  and  pain  are  greater  in  the  morning  after  rest. 
Longer  rest  increases  the  stiffness;  overexertion  increases  the  subjective 
discomfort;  moderate  use  acts  favorably.  The  subjective  weakness  of 
the  limb  is  explained  by  the  early  atrophy  of  the  thigh  muscles,  espe- 
cially the  quadriceps.  Later  the  irregular  thickening  of  the  joint 
becomes  even  more  distinct,  and  eventually  the  limb  is  disabled.  If  the 
ligaments  are  relaxed  or  destroyed,  there  are  often  a  certain  looseness 
and  abnormal  lateral  mobility.  The  skin  is  unchanged  and  freely 
movable.  Suppuration  is  rare;  fever  is  entirely  absent.  The  course 
of  the  disease  is  extremely  chronic,  advancing  gradually  with  exacer- 
bations. 

Treatment. — The  treatment  is  almost  powerless  to  combat  the  de- 
forming process.  Preparations  of  iodine,  arsenic,  quinine,  iron, 
salicylic  acid,  etc.,  have  been  used  internally,  usually  without  success. 
Warm  baths,  often  so  beneficial  in  chronic  rheumatism,  are  seldom 
tolerated;  moderate  use  of  cold  water,  douches,  careful  massage,  and 
gymnastics  often  alleviate  the  discomfort.  Immobilization  is  counter- 
indicated  as  long  as  motion  is  possible.     Later,  a  supporting  apparatus 


FREE  BODIES  IN  THE  KNEE-JOINT.  621 

made  of  silicate  or  plaster  or  a  leather  sheath  fixing  the  knee  extended  is 
almost  indispensable. 

In  view  of  the  unfavorable  prognosis,  improvement  has  been  attempted 
by  operation,  especially  in  recent  years,  as  in  chronic  articular  rheu- 
matism. In  the  early  stages  the  condition  has  been  benefited  by 
lavage  with  a  2  to  3  per  cent,  carbolic  acid  solution  or  by  injecting 
iodoform-glycerin.  If  free  bodies  are  present,  a  good-sized  trocar 
should  be  used;  but  if  they  are  large,  free  incision  is  necessary.  If 
the  villous  formation  is  extensive,  partial  or  total  excision  of  the  cap- 
sule and  removal  of  the  growths  are  indicated.  Schiiller,  Muller,  Frank, 
and  Weyprecht  report  instances  of  improvement  and  complete  recovery. 
If  unsuccessful  or  if  the  disease  is  more  advanced,  resection  is  to  be  con- 
sidered to  relieve  the  pain  and  partially  restore  the  function;  it  has  been 
successful,  although  the  cases  are  too  few  to  admit  of  a  definite  estima- 
tion of  its  value;  bony  union  of  the  stumps  was  often  delayed  or  failed 
entirely.     Very  severe  cases  may  require  amputation. 


FREE  BODIES  IN  THE  KNEE-JOINT. 

The  free  bodies  in  arthritis  deformans,  as  was  mentioned  in  the 
previous  section,  are  detached  fragments  of  bone  and  cartilage  from 
the  border  or  surface  of  the  joint,  villi  containing  cartilage  or  bone, 
rarely  plates  of  lime  or  bone  forming  originally  in  the  fibrous  capsule 
and  detached  as  the  synovialis  protruded  into  the  cavity,  or  calcified 
fibrinous  deposits.  Often  many  such  are  found  in  the  joint,  vary- 
ing in  size  from  that  of  a  millet-seed  to  that  of  a  walnut  or  larger; 
if  they  are  numerous  the  smaller  predominate.  They  are  round,  or 
shaped  like  an  egg,  almond,  or  kidney,  convex  on  one  side  and  concave 
on  the  other,  and  often  have  a  pedicle;  some  are  fibrous,  the  majority 
cartilaginous  or  bony;  some  have  a  nucleus  of  cartilage  covered  with 
bone,  some  a  nucleus  of  bone  covered  with  cartilage;  others  a  calcified 
or  osteoid  substance  in  the  cartilage. 

Although  multiple  free  bodies  occur  chiefly  in  old  people  with  several 
joints  affected,  cases  of  arthritis  deformans  are  not  infrequently  seen 
limited  to  the  knee-joint  in  younger  subjects;  the  free  bodies  are  fewer, 
but  their  typical  symptoms  are  prominent  in  contrast  to  those  of  the 
chronic  affection.     (Fig.  3S5.) 

Free  bodies,  aside  from  those  referable  to  deforming  inflammation, 
are  found  more  frequently  in  the  knee  than  in  any  other  joint.  In  an 
otherwise  healthy  joint  they  represent  detached  portions  of  the  joint- 
cartilage.  A  piece  of  the  underlying  bone  is  frequently  broken  off  with 
the  cartilage,  and  the  defect  in  the  surface  is  often  discovered  at  the  time 
of  the  operation.  These  bodies,  usually  from  one  to  four  in  number,  are 
about  the  size  of  a  bean,  exceptionally  larger,  and  consist  of  cartilage 
or  of  cartilage  and  bone,  one  side  being  covered  with  typical  cartilage, 
the  other  with  rough  bone  or  fibrous  tissue;  the  bone  attached  to  the 
cartilage  can  be  completely  covered  in  by  growth  of  the  latter. 


622 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


The  etiology  is  still  contested;  in  many  eases  there  is  a  history  of 
more  or  less  remote  trauma,  too  slight,  however,  to  explain  the  detach- 
ment of  sound  cartilage;  in  others  trauma  is  absent,  so  that  Konig  pre- 
sumes a  peculiar  insidious  inflammation,  an  osteochondritis  dissecans, 
separating  or  loosening  the  cartilage.  He  distinguishes  three  stages: 
the  body  lies  in  a  pit  in  the  cartilage  and  is  still  attached  to  it  by  fibrous 
tissue;  later  it  is  lifted  away  from  the  surface,  but  is  still  united  by  a 
broad  pedicle  of  granulation-tissue;  in  the  third  stage  it  is  only  held  by 
a  thin  pedicle  and  becomes  free  if  this  is  torn.     Barth  recognizes  only 


Fig.  385. 


Free  body  in  the  knee-joint. 


Bruns.) 


a  traumatic  origin,  slighter  force  being  necessary  than  is  generally  sup- 
posed; beside  a  fall  or  blow,  forced  movements,  especially  rotation, 
may  act.  The  lesion  so  frequently  found  on  the  internal  condyle  near 
the  intercondyloid  fossa  is  explained  by  Barth  as  being  due  to  the 
laceration  of  the  crucial  ligaments  caused  by  sudden  rotation  of  the  leg. 
Vollbrecht,  Schmieden,  and  others  also  assume  a  traumatic  origin. 
Thus  far  great  violence  has  been  necessary  experimentally  to  detach 
fragments  from  the  articular  surfaces  (Kragelund) ;  the  fragments  de- 
tached subcutaneously  with  the  chisel  in  animals  have  never  been  found 


FREE  BODIES  IN  THE  KNEE-JOINT.  G23 

free  in  the  joint  later,  but  either  adherent  to  the  capsule  or  to  the  joint- 
surfaces,  or  not  found  at  all — that  is,  they  were  absorbed.  (Hildebrand, 
Barth.) 

Symptoms. — The  multiple  bodies  present  in  pathological  joints  are 
apt  to  produce  no  more  disturbance  than  those  of  arthritis  deformans. 
On  the  other  hand,  the  free  or  pedunculated  bodies  in  joints  otherwise 
sound  or  only  diseased  in  places  commonly  give  a  very  characteristic 
picture.  According  to  Konig,  the  disease  is  often  ushered  in  by  vague, 
so-called  rheumatic  pains  in  various  joints,  which  soon  become  local- 
ized. This  is  followed  by  a  peculiar  crepitus,  functional  impairment, 
and  often  by  hydrops;  later  are  added  spontaneously  or  after  trauma 
the  characteristic  symptoms  of  a  free  body.  Occasionally  at  the  moment 
of  a  more  or  less  severe  fall  or  blow  upon  the  knee,  a  sprain,  or  quick 
forced  movement,  the  patient — in  the  large  majority  of  cases  an  other- 
wise healthy  person  between  fifteen  and  thirty — feels  an  intense  pain, 
is  unable  to  walk,  and  later  presents  the  symptoms  of  an  acute  serous 
synovitis  or  hsemarthrosis;  or  there  may  be  no  severe  disturbance  and 
the  patient  is  able  to  go  about  his  work;  the  effusion  subsides  and  per- 
haps only  moderate  swelling  is  left,  with  a  tendency  to  become  fatigued 
easily.  Suddenly  at  the  end  of  weeks,  months,  or  years,  while  walking 
there  is  an  intense  pain  in  the  knee,  and  the  leg,  usually  in  the  extended 
position,  cannot  be  bent;  passively  it  is  often  moved  only  with  great 
difficulty.  The  pain  can  be  so  severe  that  the  patient  may  faint.  After 
a  few  seconds  or  minutes  the  knee  can  be  moved,  the  intense  pain 
becomes  endurable,  a  slight  effusion  follows  and  disappears  in  a  few 
days.  This  is  repeated  within  a  varying  length  of  time,  clays  or  months, 
and  if  frequent  is  liable  to  produce  a  permanent  hydrarthrosis.  The 
body  is  probably  caught  between  the  capsule  and  the  joint-surfaces, 
never  between  the  joint-surfaces  themselves;  Larsen  verified  this  by  an 
operation  performed  during  an  attack. 

Diagnosis. — Although  the  above  symptoms  always  arouse  suspicion 
of  a  free  body  or  displaced  meniscus,  the  diagnosis  is  uncertain  until 
the  body  can  be  felt  by  direct  palpation.  This  may  be  difficult;  in 
some  instances  the  patient  may  feel  the  body,  in  others  careful  repeated 
examinations  may  be  necessary  to  discover  it.  It  may  slip  about  from 
one  part  of  the  joint  to  the  other.  It  is  most  frequently  felt  in  the 
upper  recess,  or  at  the  side  of  the  patella  or  patellar  ligament  after 
stroking  it  downward  with  the  hand  laid  flat  upon  the  joint. 

Treatment. — Except  in  arthritis  deformans  or  with  severe  secondary 
changes  following  frequently  recurring  synovitis,  the  prognosis  is 
favorable  if  the  free  body  can  be  removed.  The  treatment  is  therefore 
purely  operative,  removal  under  aseptic  precautions,  preferably  under 
application  of  the  Esmarch.  The  formerly  recommended  bloodless 
and  subcutaneous  methods  no  longer  apply.  One  should  not  operate 
unless  the  body  is  felt  and  can  be  fixed  with  the  fingers.  If  the  incision 
is  made  directly  upon  the  free  body,  it  usually  pops  out;  otherwise,  as, 
e.g.,  during  preparation  for  the  operation,  it  may  slip  into  the  joint-cleft 
or  a  pocket  and  not  be  found.     The  incision  should  not  be  too  small  as 


624  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

there  may  be  several  bodies,  and  the  edges  of  the  wound  should  be  well 
retracted.  Irrigation  is  generally  unnecessary  unless  there  are  chronic 
inflammatory  changes,  when  a  carbolic  solution  is  advisable.  If  asepsis 
is  assured,  the  incision  is  usually  closed  without  drainage.  If  there  is 
a  circumscribed  deforming  inflammation,  it  is  well  to  remove  the  dis- 
eased part  of  the  capsule,  irrigate,  and  then  drain. 


NEUROPATHIC  AFFECTIONS  OF  THE  KNEE-JOINT. 

Neuralgia  or  neurosis  of  the  joint,  so-called,  is  a  rare  condition  affect- 
ing the  knee-joint  preferably,  and  characterized  by  high-grade  sub- 
jective disturbances  with  complete  absence  of  anatomical  changes. 
Among  80  cases  v.  Esmarch  found  38  of  the  knee.  It  is  most  common 
in  women,  especially  pale,  chlorotic  individuals,  less  so  in  men.  After 
slight  trauma,  a  blow,  fall,  or  sprain  affecting  the  knee,  or  without 
apparent  cause,  the  patient  complains  of  attacks  of  more  or  less  severe 
temporary  pain  in  the  knee.  Usually  the  pain  is  increased  by  use; 
exceptionally  Berger  observed  that  it  decreased  on  use  and  increased 
during  rest.  Pressure  at  certain  parts  of  the  joint — Yalleix's  pressure 
points — was  painful,  especially  on  the  inner  condyle  close  to  the  patella 
(v.  Esmarch),  at  the  outer  margin  of  the  patella  below  its  tip,  and  just 
behind  the  head  of  the  fibula  (Berger).  In  recent  cases  the  skin  over 
the  joint  is  hyperaesthetic,  a  light  touch  often  producing  more  pain 
than  deep  pressure.  Jarring  of  the  joint-surfaces  upon  each  other  is 
painless.  Paresthesias  appear  later,  diminished  sensibility,  formica- 
tion, vasomotor  disturbances,  the  skin  being  red  and  hot  or  pale  and 
cold;  in  old  cases  there  is  often  anaesthesia.  The  knee  is  usually  held 
extended  stiffly;  rarely  there  is  a  flexion  contracture. 

The  most  careful  objective  examination  reveals  no  cause  for  the  pain 
or  contracture;  passive  motion  meets  with  energetic  muscular  resist- 
ance; sometimes  by  diverting  the  patient's  attention,  the  knee  can  be 
flexed;  the  contracture  and  pain  disappear  during  sleep.  The  diag- 
nosis of  "joint-neurosis"  can  be  made  only  upon  the  discrepancy 
between  the  objective  findings  and  subjective  disturbance,  and  then 
only  very  reservedly,  such  a  neurosis  has  repeatedly  turned  out  to  be 
a  slowly  developing  tuberculosis.  Home  saw  a  case  of  neuralgia  of 
the  joint  with  aneurism  of  the  popliteal  artery.  A  free  body  too  small 
to  be  felt  if  caught  repeatedly  may  lead  to  diagnostic  error;  temporary 
swelling,  slight  effusion,  and  oedema,  as  reported  in  neurosis,  if  found, 
make  the  diagnosis  even  more  doubtful.  According  to  Sayre,  the  neu- 
rosis usually  appears  sooner  after  trauma  than  a  disease  of  the  joint, 
and  the  body  temperature  is  often  subnormal.  The  affection  is  chronic, 
inclined  to  recur,  and  often  lasts  for  years. 

Treatment. — The  treatment  consists  chiefly  in  strengthening  the 
general  condition  and  the  nerves  by  appropriate  hygiene;  otherwise  it 
is  largely  psychic,  suggestive.  Locally  massage,  gentle  motion,  douches, 
mud  compresses,  and  electricity,  especially  the  constant  current,  may 


NEUROPATHIC  AFFECTIONS  OF  THE  KNEE-JOINT.  625 

be  tried.  Immobilization  is  injurious;  the  patient  should  be  com- 
pelled to  exercise  moderately.  Exercise  with  apparatus  is  very  bene- 
ficial, and  should  be  continued  for  some  time  after  recovery  is  apparent, 
to  prevent  recurrence. 

The  arthropathy  of  Charcot  following  diseases  of  the  central  nervous 
system,  especially  tabes,  and  occurring  chiefly  in  the  knee,  is  more  fre- 
quent than  was  formerly  supposed.  Among  74  patients  with  112 
joint-affections,  Rotter  found  the  knee-joint  involved  in  49;  and  among 
26  cases  of  tabes  with  symmetrical  joints  involved  there  were  1 1  with 
bilateral  disease  of  the  knee.  Occasionally  the  disease  begins  before 
the  ataxia,  but  commonly  it  comes  after  it  and  develops  suddenly  with- 
out recognizable  cause  or  after  slight  trauma,  the  joint  being  firmly  dis- 
tended by  the  effusion  in  a  few  hours  or  in  one  or  two  days.  The  skin 
is  of  normal  color,  but  its  veins  are  often  greatly  dilated.  The  local 
swelling  is  rapidly  followed  by  a  diffuse,  firm  oedema  of  the  limb,  reach- 
ing to  the  ankle  and  to  the  middle  of  the  thigh;  the  oedema  may  be  soft 
or  resist  pressure  of  the  finger  without  pitting.  It  is  still  uncertain 
whether  this  oedema  is  due  to  dissemination  of  the  effusion  through  a 
tear  in  the  capsule — a  condition  repeatedly  verified  by  autopsy — or  to 
vasomotor  disturbance.  During  motion  distinct  bony  crepitus  can  be 
felt  in  the  swollen  joint;  occasionally  crepitus  has  been  noticed  by  the 
patient  previous  to  the  swelling  and  missed  later.  In  the  majority  of 
cases  the  patient,  whose  attention  was  first  called  to  the  joint-affection 
by  the  swelling,  regarding  himself  as  perfectly  healthy  and,  ignorant  of 
his  nervous  affection,  has  said  nothing  about  the  knee;  this  is  explained 
by  the  characteristic  painlessness  of  the  joint.  So  the  patient  con- 
tinues to  go  about  until  the  advanced  destruction  of  the  joint  makes 
walking  impossible. 

By  appropriate  protection,  rest  in  bed,  envelopment  of  the  limb  and 
fixation  upon  a  splint  the  swelling  of  the  joint  and  soft  parts  may  dis- 
appear in  a  few  weeks  or  months  and  the  limb  be  again  rendered  useful, 
the  permanent  crepitus  being  the  only  sign  of  the  tabetic  joint  affection. 

Far  more  frequent  than  this  benign  form  so  called  by  Charcot,  is  the 
malignant  form  causing  severe  destruction  of  the  joint  in  a  few  weeks 
or  months;  the  marked  distention  of  the  capsule  leads  early  to  the  pro- 
duction of  a  loose  joint,  abnormal  lateral  mobility,  pronounced  hyper- 
extension  and  abduction  of  the  leg;  the  latter,  a  genu  valgum  recurva- 
tum,  is  at  least  the  rule,  the  varus  position  rare.  In  the  joint  can  be 
felt  a  number  of  small  or  large  hard  irregular  bodies  movable  upon  each 
other,  the  detached  fragments  of  the  surfaces  or  deposits  from  the  cap- 
sule. There  are  often  multiple  fractures  of  the  joint,  avulsion  or  multiple 
fractures  of  one  or  both  condyles  or  tuberosities.  Even  then,  as  the 
affection  is  painless,  the  patient  goes  about,  finally  in  a  splint,  until  the 
looseness  or  the  fractures  so  destroy  all  stability  that  the  legoften  depends 
from  the  thigh  as  if  attached  merely  by  a  band  (jambe  de  polichinelle). 

Pathologically  the  tabetic  joint  is  very  similar  in  appearance  to  that 
of  arthritis   deformans:  Irregular  plates   of  bone   in   the   dilated   and 
greatly    thickened    (£    inch)    capsule;  villous    growths;  the    cartilages 
Vol.  III.— 40 


526  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

frayed,  eroded,  and  furrowed  with  polished  grooves;  tuberous  growths 
of  cartilage  at  the  attachments  of  the  capsule;  the  underlying  bone 
rarefied,  porous,  and  brittle.  In  deforming  arthritis  the  severe  changes 
are  gradual  and  chronic;  in  the  tabetic  joint  the  destruction  is  rapid, 
reaching  a  high  grade  in  a  few  weeks;  in  the  former  effusion  is  absent 
or  slight,  never  reaching  the  amount  seen  in  the  latter.  Without  dis- 
cussing the  question  as  to  whether  the  tabetic  joint  is  a  disease  sui 
generis  or  not,  it  is  probable  that  the  rapid  destruction  of  the  joint  is  due 
partly  to  the  greater  insults  and  burden  to  which  the  joint  is  subjected 
by  reason  of  the  ataxia  and  anaesthesia,  partly  to  trophic  changes  increas- 
ing the  vulnerability  of  the  tissues,  especially  an  abnormal  brittleness  of 
the  bone.  Suppuration  may  occur  secondarily  and  obscure  the  typical 
symptom-complex. 

The  prognosis  of  the  malignant  form  is  unfavorable;  the  benign 
affection  can  come  to  a  standstill,  but  later  may  become  malignant. 

The  treatment  consists  in  immobilizing  the  joint  with  pressure  during 
the  stage  of  effusion;  later  in  the  use  of  supporting  apparatus  of  plaster, 
silicate,  leather  sheaths,  etc.  Resection  has  always  given  a  useless  loose 
joint.  If  a  supporting  apparatus  is  unavailing,  amputation  of  the 
thigh  and  a  good  artificial  limb  may  still  make  locomotion  possible. 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  KNEE-JOINT. 

The  cicatricial  contractures  of  the  knee,  due  to  trauma,  burns,  exten- 
sive syphilitic  ulcers  in  the  popliteal  space,  etc.,  are  treated  on  general 
principles;  gradual  stretching  of  the  cicatrix  in  recent  aid  excision  in 
old  cases,  combined  finally  with  tenotomy  and  transplantation  of  skin 
or  plastic  flaps.     Hysterical  contracture  has  been  mentioned. 

Bv  far  the  greater  majority  of  all  contractures  and  ankyloses  of  the 
knee  are  due  to  changes  in  the  joint  following  injury  or  seropurulent, 
purulent,  or  fungous  inflammation  of  the  joint.  The  processes  most 
frequentlv  producing  contracture  were  discussed  in  the  previous  chap- 
ter; of  these  the  most  common  and  most  important  is  tuberculosis. 

Froriep  has  shown  that  the  former  view,  that  the  contracture  is  refer- 
able solelv  to  shortening  of  the  muscles,  is  untenable,  and  that  all  the 
tissues  in  the  concavity  of  the  curvature,  the  skin,  muscles,  and  espe- 
ciallv  the  fascia,  the  ligaments,  and  capsule  of  the  joint,  take  part  in  this 
retraction.  To  this  shrinkage  of  the  tissues  are  added  the  adhesions 
between  the  capsule  and  the  joint-surfaces  and  between  the  surfaces 
themselves,  the  extent  of  the  same  varying  according  to  the  nature  and 
duration  of  the  original  process,  being  limited  in  some  instances  to 
small  spots  or  in  others  extending  throughout  the  contiguous  surfaces. 
Frequentlv  the  only  adhesion  in  the  joint  is  that  of  the  patella  to  the 
trochlea. 

From  the  dominant  action  of  the  flexors  of  the  leg  there  is  usually  a 
flexion  contracture  at  an  angle  of  120  to  140  degrees,  less  often  either 
obtuse  or  very  acute  at  about  30  to  40  degrees.     It  is  often  associated 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  KNEE-JOINT.     627 

with  abduction  and  outward  rotation  of  the  leg  and  outward  displace- 
ment of  the  patella;  rarely,  if  the  inner  condyle  and  tuberosity  are 
partially  destroyed,  with  adduction.  Marked  flexion  is  liable  to  be  com- 
bined  with  backward  subluxation  of  the  leg  as  a  result  of  the  destruction 

of  the  posterior  part  of  the  capsule;  under  Tuberculosis  of  the  Knee- 
joint  it  lias  been  seen  that  it  may  result  from  improper  attempts  at 

extension. 

The  determination  as  to  whether  the  surgeon  is  dealing  with  complete 
or  partial  ankylosis  is  important — and  is  occasionally  possible  only 
under  complete  anaesthesia — for  the  future  treatment,  as  complete 
ankylosis  counterindicates  any  attempt  to  restore  the  mobility.  Full 
restoration  of  function  is  only  possible  in  the  cases  with  slight  adhesions 
in  the  joint  and  moderate  shrinkage  of  the  capsule,  such  as  are  seen 
after  prolonged  immobilization  in  plaster-splints  or  in  younger  patients 
after  slight  seropurulent  arthritis.  In  all  other  cases  the  surgeon  will 
have  to  be  content  with  improving  the  mobility  or  the  malposition. 
Such  correction  is  to  be  considered  almost  solely  in  the  cases  of  bony 
ankylosis.  The  question  of  interference  or  non-interference  must 
depend  upon  the  degree  of  functional  disturbance.  The  latter  is  nat- 
urally always  great  if  the  limb  is  shortened  by  ankylosis  at  a  right  or 
acute  angle.  Bony  ankylosis  in  full  or  almost  full  extension  is  a  noli  me 
tangere,  as  with  such  long  marches,  protracted  hard  work,  and  standing 
or  walking,  are  possible  if  stooping  is  not  necessary;  many  individuals 
learn  to  dance  and  use  the  limb  so  deftly  that  the  slight  limp  is  not 
noticeable  to  the  untrained  eye. 

Prognosis. — The  prognosis  of  a  contracture  depends,  aside  from  the 
degree  of  mobility  present,  upon  whether  the  original  process  has 
healed  or  not.  An  attempt  to  overcome  the  contracture  is  not  infre- 
quently followed  immediately  by  fever  and  lighting  up  of  the  purulent 
or  tuberculous  inflammation.  Fistulas  if  not  eradicated  at  the  time 
of  operation  make  the  prognosis  especially  unfavorable.  The  achieve- 
ment of  a  movable  joint  depends  very  much  upon  the  perseverance  and 
energy  of  the  patient.  All  attempts  at  mobilization  are  often  very 
painful  and  usually  necessitate  long-continued  treatment.  If  the 
patient  does  not  possess  energy  enough  to  endure  the  pains  connected 
with  the  necessary  active  or  passive  movements,  the  surgeon's  efforts 
are  in  vain.  In  time  the  almost  involuntary  movements  of  the  knee  in 
using  the  limb  may  restore  a  fair  amount  of  motion;  in  the  majority  of 
cases,  however,  the  stiffness  gradually  increases  and  the  flexion  becomes 
more  acute. 

Treatment. — In  recent  mild  cases  methodical  exercise  continued 
energetically  with  active  and  passive  flexion  and  extension,  repeated 
several  times  daily,  is  usually  sufficient.  The  patient  can  flex  the  leg 
passively  with  the  hands  or  with  a  strip  of  cloth  or  a  handkerchief 
passed  around  the  foot,  and  extend  it  by  means  of  a  rope  and  pulley 
attached  to  an  upright  at  the  foot  of  the  bed.  Pendulum  movements, 
namely,  swinging  the  leg  back  and  forth  with  the  hands  while  sitting  on 
the  edge  of  the  bed,  are  beneficial. 


628 


DISEASES  IN  AXD  ABOUT  THE  KXEE-JOIXT. 


Passive  motion  alone  is  never  sufficient;  strengthening  the  muscles 
by  active  use  is  indispensable  to  overcome  the  stiffness  and  correct 
any  false  position.  Active  motion  and  massage  of  the  thigh  muscles 
are  therefore  as  important  as  passive  motion,  their  application,  how- 
ever, presupposing  previous  partial  mobilization  by  passive  movements 
and  the  proper  condition  of  the  muscles.  Active  extension  is  often  pre- 
vented by  adhesion  of  the  patella  to  the  condyles;  aside  from  the  fre- 
quent complete  ankylosis  of  tuberculosis,  it  is  usually  the  more  acute 
inflammations,  especially  gonorrhoea,  which  cause  adhesion,  fibrous  or 
bony,  of  the  patella  to  the  femur  and  partial  limitation  of  motion  and  a 
moderate  flexion  position.  The  patella  may  be  loosened  by  lateral 
pressure,  light  blows  of  the  hammer,  or  by  driving  a  wooden  wedge 
between  the  patella  and  condyle,  meanwhile  protecting  the  soft  parts 

Fig.  386. 


3= 


Schede's  weight-extension  for  stretching  flexion  contractures  of  the  knee  with  backward 

subluxation. 


(Hiiter) ;  but  usually  open  or  subcutaneous  separation  with  the  chisel  is 
necessary.  Helferich  and  Cramer  interposed  a  flap  from  the  vastus 
internus  to  prevent  later  adhesion  of  the  patella  and  to  give  a  movable 
joint.  The  mobilization  of  the  patella  should  be  followed  by  energetic- 
passive  and  active  motion. 

In  cases  of  apparently  moderate  fibrous  adhesions  in  which  mobiliza- 
tion is  very  painful — for  example,  after  the  synovitis  due  to  long  immo- 
bilization—it is  best  to  break  up  these  adhesions  under  anaesthesia  by 
forcible    extension    and    flexion.     A    marked  serosanguineous  effusion 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  KNEE-JOINT.     629 


Fig 


always  follows,  but  disappears  rapidly  under  compression  and  massage. 
Gentle  motion  should   be  begun  in  twenty-four  to  forty-eight   hours 

afterward.  The  pain  at  the  outset  is  lessened  by  an  ice-bag  and 
morphine  hypodermically,  and  usually  subsides  rapidly  and  entirely. 

Continuous  weight-extension  is  the  most  comfortable,  effectual,  and 
often  the  most   rapid   means  of  correcting  the   flexion  contracture  of 

older  eases.  The  extension  adhesive  strips  are  applied  to  the  leg  in  the 
usual  manner  and  8  to  10  pounds  attached.  The  leg  may  he  suspended 
meanwhile  by  an  anterior  plaster  strip 
reaching  to  the  knee  and  having  three  rings 
incorporated  along  the  middle  line  for  the 
pulley  ropes.  A  loosely  filled  sand-bag  is 
laid  upon  the  thigh  above  the  knee  or  a 
loop  and  weight  applied  at  the  same  point 
to  increase  the  action.  If  there  is  a  ten- 
dency to  backward  dislocation  of  the  leg, 
Schede's  method  may  be  employed.  (Fig. 
38G.)  For  young  children  the  weight  should 
be  about  10  pounds,  for  adults  25  to  30 
pounds.  The  flexion  contracture  may  yield 
entirely  in  a  few  days,  or  only  to  a  certain 
point  and  resist  protracted  extension.  In 
the  latter  case,  if  it  cannot  be  overcome 
sufficiently  under  anaesthesia  by  forcible 
extension,  operation  is  to  be  considered. 

The  ambulant  method,  by  means  of 
numerous  apparatus  with  or  without  pre- 
vious extension  by  weight,  has  been  tried, 
and  is  preferred  by  many  orthopaedists. 
Fig.  387  illustrates  the  principle  of  the 
various  apparatus.  The  action  of  all  ap- 
paratus with  a  simple  hinge-joint  is  faulty, 
analogous  to  the  improper  method  of 
manual  extension  described  previously,  by 
which  the  joint-surfaces  are  easily  com- 
pressed instead  of  being  separated.  The 
proper  action  is  a  combination  of  exten- 
sion and  traction  as  effected  by  the  sector 
splints  of  Stillmann  and  Braatz  shown  in 
Figs.  388,  389,  and  390. 

Forcible  extension — brisement  force — 
acts  much  quicker.     Grasping  the  thigh 

and  leg  close  to  the  knee,  the  latter  is  extended  forcibly  while  an 
assistant  makes  traction  on  the  leg  in  its  axis.  One  can  often  feel 
and  hear  the  fibrous  or  cartilaginous  adhesions  give.  The  correction 
is  sometimes  facilitated  by  previously  bending  the  knee  forcibly  or 
dividing  the  tendons  which  are  on  the  stretch,  v.  Langenbeck  places  the 
patient  in  the  abdominal  position  with  the  knee  at  the  edge  of  the  table 


Hessing's  apparatus  for  stretching 
flexion  contractures  of  the  knee. 


630 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOIST. 


and  the  thigh  held  down  by  an  assistant;  thus  the  operator  adds  the 
weight  of  his  body  to  the  strength  of  his  hands.  The  method  as  recom- 
mended by  Bonnet  often  works  very  rapidly.  But  in  general  forcible 
correction  is  employed  much  less  than  formerly  on  account  of  its  dis- 


Fig.  388. 


Fig.  389. 


Fig.  300. 


Braatz'  sector  splint. 


advantages:  The  posterior  part  of  the  capsule  can  be  torn;  the  tibia 
dislocated  backward;  the  tibia  or  femur  fractured  at  the  joint,  or  the 
tibia  forced  into  the  softened  spongiosa  of  the  condyles.  The  head  of 
the  tibia  should  therefore  be  pushed  forward  as  the  leg  is  extended. 
Latent  suppuration  can  be  lightened  up;  the  popliteal  vessels  can  be 


CONTRACTURE  AND  ANKYLOSIS  OF  THE  KNEE  JOINT.    G31 

torn  and  gangrene  or  aneurism  follow  if  the  soft  parts  are  contracted 
and  adherent  about  the  popliteal  space. 

All  these  dangers  warn  against  injudicious  or  too  frequent  use  of 
forcible  extension.  Further,  they  make  clear  the  advantage  of  gradual 
extension  in  several  sittings  at  intervals  of  two  or  three  weeks  with  the 
application  of  a  plaster-splint  after  each  correction  if  the  resistance  is 
great.  Forcible  correction  is  only  suitable  for  cases  of  fibrous  adhesions 
with  simple  flexion  contracture;  a  pronounced  valgus  position  usually 
resists  satisfactory  correction.  It  is  counterindicated  by  fistulas  and 
especially  after  acute  suppuration — for  example,  acute  osteomyelitis. 
Recently  Lorenz  recommended  a  modification  after  the  method  had 
been  abandoned  by  most  of  the  German  surgeons  in  severe  cases  for 
operation.  Instead  of  manual  correction,  he  uses  an  apparatus  of  his 
own  in  which,  with  the  patient  in  the  lateral  position,  the  thigh  is  held 
firmly  between  two  well-padded  jaws  (as  in  a  mitre-box)  and  the  head 
of  the  tibia  pulled  forward  slowly  on  the  condyles  by  means  of  a  sling 
and  screw.  In  this  way  eccentric  fractures  and  laceration  of  the  soft 
parts  of  the  popliteal  space  are  said  to  be  avoided.  Lorenz  states  that 
he  has  used  it  in  300  cases  without  any  bad  results;  that  it  is  entirely 
harmless,  guarantees  the  preservation  of  all  skeletal  parts,  can  be  per- 
formed quickly  with  the  patient  ambulant,  and  in  many  cases  gives  an 
actively  movable  joint.  There  is  no  question  that  this  procedure, 
termed  "instrumental  moulding  intra-articular  redressement,"  is  more 
effectual  and  less  violent  than  manual  brisement  force.  The  dangers 
are  not  regarded  as  so  slight  by  the  majority  of  German  surgeons,  how- 
ever, even  when  the  method  is  limited  (as  required  by  Lorenz)  to  cases  in 
which  the  inflammation  has  apparently  healed  entirely.  It  therefore 
needs  further  testing.  The  after-treatment  consists  in  the  application 
of  a  removable  plaster-  or  silicate-splint  or  apparatus  which  is  worn  for 
some  time;  massage  and  exercises,  preferably  with  medico-mechanical 
apparatus,  serve  to  strengthen  the  muscles  and  aid  the  desired  result. 
Recurrence,  namely,  a  flexion  contracture,  is  unfortunately  frequent 
in  spite  of  the  greatest  care.  To  prevent  it  Heusner  advises  trans- 
planting one  or  more  flexor  tendons  to  the  tendon  of  the  quadriceps,  an 
operation  performed  successfully  by  him  in  3  cases,  the  flexed  joints 
extending  of  themselves  after  transplantation. 

Bony  ankylosis  is  not  properly  an  indication  for  the  usual  method  of 
forcible  correction,  but  the  unintentional  fractures  which  occasionally 
resulted  from  its  application  and  were  followed  by  favorable  results 
gave  rise  to  the  introduction  of  osteoclasis  for  the  treatment  of  bony 
ankylosis.  A  good  result  is  possible  only  when  the  fracture  is  made 
close  to  the  joint.  By  the  modern  methods  of  Robin,  Collin,  and 
Lorenz  it  is  now  possible  to  produce  the  fracture  at  any  desired  level. 
According  to  Oilier  supracondylar  osteoclasis  is  preferable;  after 
transverse  fracture  above  the  condyles  the  lower  fragment,  an kylosed 
at  an  angle  to  the  tibia,  is  pushed  backward  slightly  to  bring  the  leg 
into  the  axis  of  the  femur.  The  results  are  not  satisfactory  if  the 
flexure  exceeds  135  degrees. 


632  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

Operative  correction  is  preferred  by  most  German  surgeons  in  spite 
of  the  improvement  offered  by  osteoclasis.  In  simple  cases,  in  which  the 
hindrance  is  caused  solely  by  the  semitendinosus  and  semimembrano- 
sus the  tendons  of  these  muscles  may  be  divided  subcutaneously,  or, 
better,  through  two  longitudinal  incisions  at  the  sides  of  the  popliteal 
space,  as  the  parts  may  thus  be  protected,  and  shrunken  tissues,  espe- 
cially the  fascia,  divided  at  the  same  time.  As  a  rule  more  extensive 
operations  are  necessary. 

Linear  osteotomy  is  of  little  use  to  overcome  ankylosis  on  account  of 
the  marked  shrinkage  of  the  soft  parts  in  the  popliteal  space.  Although 
performed  at  the  same  level  as  supracondylar  osteoclasis,  Konig's  inci- 
sion is  preferable:  He  divides  the  soft  parts  transversely  down  to  the 
bone  at  the  level  of  the  tibial  spine,  and  with  a  broad  chisel  divides  the 
bone  from  this  point  obliquely  upward  and  backward.  As  the  bone  is 
often  soft  with  old  contractures  or  ankyloses,  the  flexure  can  sometimes 
be  overcome  fully  by  forcible  traction.  If  this  is  possible,  aside  from 
its  simplicity  the  operation  has  the  advantage  of  preserving  the  bone, 
especially  the  epiphyseal  line  in  children ;  if  impossible,  a  wedge  with 
base  in  front  may  be  excised. 

Bony  ankylosis  at  a  right  or  acute  angle  necessitates  wedge-shaped 
osteotomy.  The  operation  was  first  performed  above  the  condyles  by 
Rhea  Barton  in  1835.  At  the  present  time  Gordon  Buck's  wedge- 
shaped  resection  at  the  joint  is  preferred.  Although  the  application  of 
the  Esmarch  is  not  indispensable,  it  facilitates  the  operation.  In  chil- 
dren the  epiphyseal  line  should  be  preserved  under  all  circumstances. 

Typical  resection  of  the  joint  is  preferable  to  cuneiform  osteotomy  in 
all  cases  in  which  the  process  is  possibly  not  entirely  healed,  particu- 
larly in  tuberculosis  with  severe  contracture  and  ankylosis;  likewise 
if  fistulas  exist  or  there  is  a  pronounced  valgus  position  or  dislocation  of 
the  leg  backward,  or  a  marked  flexure  with  only  slight  mobility.  The 
joint  is  opened  through  a  transverse  incision  below  or  through  the 
patella,  the  adhesions  in  the  joint  separated,  the  crucial  ligaments 
divided,  and,  according  to  Koch,  the  shrunken  soft  parts  in  the  popliteal 
space,  and,  in  the  case  of  genu  valgum  on  the  outer  side  of  the  joint, 
are  mobilized  as  much  as  possible.  While  carefully  protecting  the  ves- 
sels and  nerves  in  the  popliteal  space,  the  shrunken  and  thickened  cap- 
sule and  ligaments  are  excised.  The  capsule,  periosteum,  and  muscles 
are  lifted  en  masse  from  the  bone  to  above  and  below  the  attachments 
of  the  capsule,  and  at  the  sides,  to  beyond  the  attachments  of  the 
lateral  ligaments;  this  is  done  not  only  on  the  popliteal  surface,  but 
also  on  the  posterior  surface  of  the  tibia,  and,  in  the  case  of  high-grade 
genu  valgum,  on  the  outer  posterior  surface  of  the  tibia  and  fibula.  In 
the  latter  case  this  is  done  most  readily  by  an  anterior  lateral  incision 
between  the  head  of  the  tibia  and  fibula.  The  appropriate  wedges, 
usually  small,  are  then  sawed  from  the  surface  of  the  bone  and  the  pos- 
terior edge  of  the  tibia  rounded  off.  If  the  extensor  tendons  are  tense, 
they  are  cut.  The  joint  is  then  extended  as  much  as  the  nerves  and 
vessels  allow,  full  extension  being  effected  later  by  means  of  plaster- 


SM 1  PPINt ;  -KNEE.  633 

splints.  Kummer  and  Helferich,  to  obviate  shortening  and  to  preserve 
the  epiphyseal  cartilage,  recommend  curved  osteotomy,  namely,  the 
removal  with  a  key-hole  saw  of  a  small  curved  wedge  of  hone  after 
thorough  open  division  of  the  tense  fascia  and  tendons  in  the  popliteal 
space.  The  curve  of  the  sawn  surface  facilitates  the  shifting  of  the  leg 
upon  the  thigh,  insures  fixation  after  correction,  and  favors  bony  union. 


PARALYTIC   DEFORMITIES   OF   THE  KNEE-JOINT. 

The  paralytic  deformities  of  the  knee-joint,  commonly  the  result  of 
anterior  poliomyelitis,  are  sometimes  in  the  form  of  a  flexion  contracture 
when  due  to  paralysis  of  the  extensors  of  the  leg,  more  often,  even  if  the 
flexors  are  intact,  a  hyperextension,  genu  recurvatum,  combined  with 
more  or  less  pronounced  genu  valgum  and  outward  rotation  of  the  leg. 
This  peculiar  deformity  is  purely  the  effect  of  the  body-weight,  as  shown 
by  v.  Yolkmann.  Normally  a  slight  amount  of  hyperextension  is  pos- 
sible in  the  knee.  In  this  position  further  extension  is  prevented  by  the 
check  ligaments,  no  longer  by  the  muscles,  as  soon  as  the  line  of  gravity 
falls  in  front  of  the  rotary  axis  of  the  knee-joint.  To  walk  then,  when 
the  extensors  are  partially  or  fully  paralyzed,  the  patient  drags  the 
limb  forward,  plants  it  in  full  extension,  and  throws  the  body-weight  in 
front  of  the  extended  knee  by  curving  the  spine  forward.  The  over- 
taxed posterior  ligaments  are  thus  gradually  stretched  and  a  genu 
recurvatum  results.  This  happens  occasionally  in  very  much  the 
same  way  in  chronic  coxitis  with  marked  shortening  of  the  limb. 

With  the  aid  of  a  sheath  apparatus  preventing  hyperextension  and 
replacing  the  action  of  the  extensors  by  strong  rubber  bands,  the  patient 
can  often  walk  very  well.  In  severe  cases  it  may  be  necessary  to  apply 
a  stiff  apparatus  fixing  the  knee  at  ISO  degrees,  or  preferably,  especially 
among  the  poor,  to  produce  ankylosis  by  arthrodesis.  As  in  typical 
resection,  the  joint  is  opened  by  a  transverse  incision,  the  cartilaginous 
surfaces  are  sawed  squarely  off,  the  capsule  being  preserved.  As  little 
cartilage  is  removed  as  possible,  to  prevent  shortening.  The  saw-cut 
should  be  made  through  bone,  but  never  through  the  epiphyseal  line. 
As  the  proliferation  of  bone  is  usually  slight  in  a  paralytic  limb,  howT- 
ever,  bony  union  is  desirable.  It  is  advisable  to  suture  or  nail  the 
stumps  together  in  full  extension.  Drainage  is  unnecessary;  a  circu- 
lar plaster-splint  is  applied  over  the  dressing  and  left  on  for  three  or 
four  weeks. 

SNAPPING-KNEE. 

"Snapping  knee" — Schnellendes  or  fedcrndes  Knie,  cjenon  a  ressort — 
is  a  rare  affection  still  little  recognized  by  German  surgeons.  It  is 
characterized  by  a  sudden  jerk  which  shakes  the  body  and  takes  place 
suddenly  while  walking,  during  the  last  part  of  extension — that  is,  be- 
yond about  an  angle  of  160  degrees.     This  snap  cannot  be  elicited  by 


634  DISEASES  IX  AND  ABOUT  THE  KNEE-JOINT. 

passive  motion  or  by  active  extension  of  the  knee  while  in  the  dorsal 
position.  The  cause  is  still  obscure.  In  the  cases  known  to  the  author 
in  the  literature  there  was  always  a  history  of  previous  trauma,  often 
one  or  two  years  before.  Objectively  no  changes  were  recognizable  in 
the  joint  in  several  instances.  Delorme  assumes  a  spasm  of  the  flexors 
as  the  cause.  Thiem  suspects  an  avulsion  of  the  posterior  crucial  liga- 
ment; normally  extension  is  checked  almost  entirely  by  this  ligament; 
if  it  is  injured,  the  las:  of  extension  occurs  with  a  jerk.  In  Delorme's 
case  the  snapping  was  stopped  for  a  time  by  bandaging  the  limb  with 
an  Esmareh. 

Prognosis. — The  prognosis  is  unfavorable. 

Treatment. — The  treatment  consists  in  stiffening  the  knee  with 
apparatus  or  by  arthrodesis,  as  massage,  electricity,  baths,  etc.,  are 
usually  ineffectual. 


STATIC  DEFORMITIES   OF  THE  KNEE. 

A  line  connecting  the  hip-joint  and  ankle  passes  normally  through 
the  intercondyloid  fossa  of  the  femur,  although  slight  deviations  occur 
physiologically.  If  the  line  falls  without  the  knee-joint,  the  condition 
is  regarded  as  pathological;  if  it  lies  to  the  outer  side,  one  speaks  of 
genu  valgum,  if  to  the  inner,  genu  varum.     (Fig.  303.) 

Genu  valgum  X-bein,  Knick-bein,  Baecker-bein,  Knock-knee). — 
In  studying  the  injuries  and  inflammations  of  the  knee-joint  we  have 
become  familiar  with  the  symptomatic  valgus  position,  the  result  com- 
monly of  changes  in  the  articular  surfaces.  Aside  from  this  variety 
of  genu  valgum  and  the  congenital  form  accompanying  congenital 
outward  dislocation  of  the  patella,  two  types  should  be  distinguished: 
1.  Rhachitic.     2.  Adolescent. 

1.  The  rhachitic  genu  valgum  occurs  during  the  "florid"  stage  of 
rickets,  namely,  between  the  first  and  fifth  year  of  childhood.  The 
abnormally  soft  bone  is  bent  by  the  weight  of  the  body  at  the  partially 
ossified  epiphvseal  cartilage  of  the  femur  or  tibia,  or  both.  Usually 
both  limbs  are  affected,  although  unequally,  in  connection  with  the 
other  changes  in  the  lower  extremities  due  to  the  same  process,  deflexion 
of  other  epiphyses,  curvature  or  infraction  of  the  shafts,  chondroma  a 
and  exostoses  at  the  junction  of  epiphysis  and  shaft,  etc.  One  meets 
most  frequently  with  a  simultaneously  outward  and  forward  convex 
curvature  of  the  shaft  of  the  femur.  The  degree  of  curvature  varies 
greatly.  The  leg,  in  addition  to  being  abducted,  is  almost  always 
rotated  outward  and  hyperextended.  In  severe  cases  there  is  almost 
without  exception  a  certain  amount  of  relaxation  of  the  capsule,  and 
especially  of  the  lateral  ligaments,  which  allows  of  abnormal  lateral 
mobility  in  extension;  occasionally  there  is  an  actual  looseness  of  the 
joint. 

2.  In  adolescents  the  condition  develops  at  the  time  of  puberty, 
between  the  thirteenth  and  eighteenth  year,  much  more  frequently  in 


STATIC  DEFORMITIES  OF  THE  KNEE. 


635 


boys  at  the  time  when  an  occupation  makes  great  demands  upon  the 
bone  during  its  second  period  of  more  rapid  growth.     So  the  deformity 

is  found  to  be  especially  common  among  those  whose  occupation  compels 
them  to  stand  for  long  periods,  as  in  bakers,  blacksmiths,  locksmiths, 
waiters,  etc.  There  is  no  doubt  that  it  is  a  pressure  deformity:  but 
it  is  still  a  disputed  question  as  to  how  the  encumbrance  acts,  whether 
only  upon  pathologically  soft  or  also  upon  normal  hone,  also  as  to  the 
place  at  which  the  curvature  occurs. 

As  to  the  nature  of  genu  valgum;  of  the  various  theories  extant  it  is 
sufficient  for  practical  purposes  to  give  the  views  of  Hiiter  and  v.  Mikulicz. 
I  Inter  maintained  that  it  was  a  change  in  conformation,  an  unequal 
growth  in  thickness  of  the  epiphyses  which  was  confined  entirely  to  the 
front  part  of  the  condyles  and  tuberosities.  An  individual  with  unde- 
veloped or  weak  muscles  seeks  to  unburden  the  tired  muscles,  if  com- 


Fig.  391. 


Fig.  392. 


Female. 


Male. 


The  normal  inclination  of  the  femora.     (Pfeiffer.) 


pelled  to  stand  for  long  periods,  by  extending  or  slightly  hyperextend- 
ing  the  knee — that  is,  the  strain,  instead  of  being  met  by  the  normal 
elastic  muscular  resistance,  is  met  by  the  check  action  of  the  ligaments 
and  bone  which  comes  into  play  in  this  position.  Normally  full  exten- 
sion is  combined  with  slight  outward  rotation  and  abduction  of  the  leg, 
the  anterior  margin  of  the  condylar  surfaces  of  the  tibia,  especially  of 
the  outer,  pressing  against  the  anterior  part  of  the  condyles  of  the  femur. 
As  an  anatomical  expression  of  this  pressure,  cue  finds  the  well-known 
check  facets  on  the  articular  surfaces  of  the  tibia,  the  outer,  as  a  rule, 
being  slightly  lower  than  the  inner.  According  to  Hiiter,  if  this  hyper- 
extensicn  is  continued  too  long  or  too  frequently  by  reason  of  the  demands 
of  an  occupation,  or  if  the  burden  is  too  great  or  the  bone  too  weak,  the 
changes  in  the  articular  surfaces,  normally  confined  within  certain 
limits,  become  more  pronounced;  the  growth  of  the  front  part  of  the 


636 


DISEASES  IX  AND  ABOUT  THE  KXEE-JOIXT. 


Fig.  393. 


outer  condyle  is  retarded  while  that  of  the  disencumbered  inner  condyle 
is  abnormally  accelerated  and  increased,  the  result  being  a  genu  valgum. 
This  explanation  of  Hiiter  was  accepted  as  very  plausible  both  on 
account  of  its  simplicity  and  its  deduction  on  mechanical  principles, 
and  also  because  it  accounted  most  readily  for  the  entire  symptom- 
complex  of  genu  valgum,  the  essentials  of  which  were  designated 
as  abduction,  increased  outward  rotation,  and  hyperextension  of  the 
leg,  and  the  complete  disappearance  of  the  valgus  position  during 
flexion. 

v.  Mikulicz'  anatomical  investigations  refuted  this  theory,  apparently 
so  well  founded.  He  compared  the  angle  between  the  shaft  of  the 
femur  and  the  line  of  the  articular  surfaces  of  the  condyles  to  the  angle 
of  the  epiphysis,  namely,  the  angle  between  the  shaft  and  the  epiphyseal 
line.  Under  normal  conditions  the  latter  is  always  only  about  2  to  6 
degrees  greater  than  the  former.  If  Hiiter's  view  is  correct  that  genu 
valgum  is  due  solely  to  a  difference  in  the  height  of  the  two  condyles, 
the  difference  in  these  two  angles  must  be  considerably  greater  in  genu 
valgum.     Measurements    of    frontal    sections    of    relevant    specimens 

failed  to  establish  any  such  difference 
in  the  height  of  the  condyles;  on  the 
other  hand,  v.  Mikulicz  found  a  very 
distinct  outward  deflexion  of  the  en- 
tire apophysis  on  the  shaft  with  ab- 
normal outward  curvature  of  the 
lower  end  of  the  shaft.  (Fig.  396.) 
The  epiphyseal  cartilage  was  broad- 
ened, especially  in  the  zone  of  the 
cartilaginous  growth,  and  the  line  of 
ossification  was  irregular.  Therefore 
the  changes  causing  genu  valgum  were 
not  in  the  epiphysis,  but  at  the  junc- 
tion of  the  epiphysis  and  shaft,  the 
deflexion  of  the  epiphysis  being  due, 
according  to  v.  Mikulicz,  to  a  form  of 
late  rhachitis.  The  same  changes  were 
found  in  the  upper  end  of  the  tibia, 
although  less  constantly,  v.  Miku- 
licz' investigations  were  later  con- 
firmed by  Macewen,  Weil,  Wolff,  and 
others,  although  the  views  still  vary  as 
to  whether  the  cause  is  a  late  rhachitis 
or  pressure. 

Albert,  in  recent  careful  investiga- 
tions, found,  in  addition  to  the  deflexion  described  by  v.  Mikulicz,  that 
the  external  condyle  of  the  femur  was  shorter,  and  that  the  correspond- 
ing condylar  surface  of  the  tibia  was  lower;  that  the  outer  condyle  was 
broadened  in  the  frontal  plane  and  rotated  backward  on  the  shaft  of 
the  femur;  in  several  instances  that  the  neck  of  the  femur  was  more 


1.  Genu  varum.     2.  Normal  limb. 
3.  Genu  valgum. 


STATIC  DEFORMITIES  OF  THE  KNEE. 


car 


vertical  and  shorter.  The  genu  valgum  was  therefore  due  not  only  to 
extra-articular,  but  also,  according  to  Albert,  to  primary  intra-artieular 
changes. 

Of  the  above  symptoms  given  by  Hiiter,  v.  Mikulicz  regarded  the 
abduction  alone  as  characteristic.  Hyperextension  and  outward  rotation 
of  the  leg  are  frequent  but  not  constant,  and  are  merely  the  result  of 
relaxation  of  the  capsule  or  of  curvature  of  the  bone  in  the  frontal 
direction  (Konig) ;  they  are  more  commonly  met  with  in  young  children 
than  in  adolescents.  The  disappearance  of  the  abduction  during  flexion 
is  only  apparent,  and  is  explained  by  a  compensating  outward  rotation 

Fir..  394. 


Adolescent  knock-knees.     Deformity  most  marked  in  the  tibia.     (Whitman.) 


of  the  thigh  at  the  hip-joint  during  flexion  of  the  knee.  If  the  lower 
end  of  the  femur  and  upper  end  of  the  tibia  are  equally  affected,  the 
shafts  of  the  two  bones  should  lie  in  the  same  plane  in  full  flexion,  as 
one  may  demonstrate  by  cutting  out  and  folding  a  piece  of  paper  having 
a  corresponding  curve.     (See  Figs.  394  and  395.) 

The  degree  of  genu  valgum  may  be  estimated  roughly  by  measuring 
the  angle  formed  by  the  axes  of  the  leg  and  thigh,  or  the  distance  of 


638 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


the  midpoint  of  the  knee-joint  from  a  line  drawn  from  the  middle  of 
the  head  of  the  femur  to  the  middle  of  the  ankle-joint  (Fig.  393),  or 
the  distance  between  the  two  heels,  or  of  each  heel  from  the  middle 
line  with  the  knees  together.  It  can  be  determined  more  accurately  by 
measuring  the  angle  formed  between  the  shaft  and  the  transverse  line 
of  the  joint.  In  all  these  measurements,  as  shown  by  Wolff,  the  muscles 
should  be  relaxed,  as  many  patients  are  able  to  overcome  the  genu 
valgum  considerably. 

If  slight,  the  deformity  may  be  concealed  by  the  clothing.  Even 
moderate  curvature  causes  considerable  disturbance,  however;  to  prevent 
the  knees  from  striking  in  walking,  the  thigh  has  to  be  abducted 
or  even  rotated  outward.    The  gait  is  therefore  peculiarly  shambling. 


Fig.  395. 


Adolescent  knock-knee,  showing  the  disappearance  of  the  deformity  when  legs  are  flexed. 

(Whitman.) 

The  muscles  tire  easily,  so  that  the  patients  are  less  and  less  able 
to  take  long  walks,  stand  for  any  length  of  time,  or  to  carry  heavy 
burdens,  hence  their  earning-efficiency  is  more  and  more  com- 
promised. 

An  abnormal  position  of  the  foot  is  often  combined  with  the  deformity, 
sometimes  flat-foot  developing  from  the  same  causes — e.  g.,  muscular 
relaxation  and  softness  of  the  bone — sometimes  an  habitual  pes  varus, 
assumed  by  the  patient  to  compensate  the  curvature  and  bring  the  foot 
flatly  to  the  ground.  Although  the  affection  is  usually  painless,  moderate 
exertion  often  produces  an  indefinite  sensitiveness  of  the  entire  limb, 
disappearing  rapidly  with  sufficient  rest  but  increasing  otherwise  to 
actual  pain. 

If  the  curvature  is  marked  and  the  limb  used  constantly,  a  chronic 


STATIC  DEFORMITIES  OF  THE  KNFF. 


639 


mm 

wMm 
MM 


inflammatory  process  not  infrequently  develops  in  the  joint,  similar 
anatomically  and  clinically  to  the  monarticular  form  of  arthritis  defor- 
mans; distinct  crepitus  can  he  felt,  the  form  of  the  articular  surfaces 
becomes  changed,  the  capsule  is 

thickened;  often  there  is  a  tran-  Fig.  396. 

sient  or  chronic  hydrops;  the 
mobility  of  the  joint  is  limited. 
In  such  instances  the  disturbance 
may  be  so  severe  as  to  entirely 
prevent  work. 

Left  to  itself,  genu  valgum 
becomes  worse  gradually  but 
steadily  as  long  as  the  abnormal 
softness  of  the  bone  and  the  in- 
jurious action  of  pressure  con- 
tinue. Occasionally  the  curva- 
ture reaches  a  high  grade  in  a 
relatively  short  time — in  a  few 
months.  These  are  the  cases 
which  cannot  be  explained  with- 
out assuming  an  abnormal  soft- 
ness of  the  bone;  the  patients 
always  complain  of  indefinite 
pain  near  the  epiphyseal  lines. 
In  children  the  curvature  comes 
to  a  standstill  as  the  bones  solid- 
ify— in  fact,  growth,  unless  in- 
jured too  much  by  the  process, 
often  produces  considerable  im- 
provement in  the  deformity. 
Such  spontaneous  improvement 
can  only  be  expected  up  to  about 
the  seventh  year;  in  severe  rha- 
chitis  with  marked  curvature  the 
prospect  of  spontaneous  recovery 
through  growth  alone  is  slight. 

Genu  valgum  adolescentium 
also  becomes  stationary  in  a  num- 
ber of  cases,  especially  if  the  occupational  harm  is  stopped.  Honsell 
found  distinct  improvement  in  6  of  12  cases  of  slight  or  moderate  grade 
when  examined  at  the  end  of  several  years;  in  a  few  instances  the  limbs 
were  straight.  Sometimes  the  affection  advances  steadily  if  not  treated, 
the  curvature  increasing  even  after  growth  is  complete  as  a  result  of 
subsequent  inflammatory  deforming  processes  in  the  joint.  As  little  is 
known  of  the  cause  of  the  difference  in  the  course  as  of  the  nature 
of  the  supposed  softening  of  the  bone  and  the  cause  of  its  origin  and 
disappearance;  the  views  as  to  late  rhachitis  are  still  at  variance. 


Frontal  section  through  the  femur  of  genu  valgum 
adolescentium.     (v.  Mikulicz.) 


640 


DISEASES  IN  AND  ABOUT  THE  KNEE  JOINT. 


Treatment. — Removal  of  the  injurious  influences  and  treatment  of 
the  underlying  disease  are  the  first  essentials  in  both  types  of  genu 
valgum. 

1.  Rhachitic  genu  valgum.  In  the  florid  stage  appropriate  hygiene, 
sunshine  and  air,  care  of  the  skin,  proper  diet,  and  administration  of 
iron,  cod-liver  oil,  phosphoric  acid,  the  iodide  preparations,  etc.,  are 
indicated.  To  keep  up  the  muscular  tone  and  general  strength  the 
child  should  be  allowed  to  go  about  in  the  open  air  in  a  walking  chair, 


Fig.  397. 


Fig.  398. 


The  Thomas  knock-knee  brace. 
(Whitman.) 


Thomas  knock-knee  braces  with  pelvic  band.  The 
pelvic  band  may  be  divided  also,  the  two  parts  being 
joined  by  straps.      (Fig.  399.)      (Whitman.) 


but  not  to  bear  the  weight  of  the  body  upon  the  limbs  to  any  extent. 
It  should  play  in  the  sunshine,  on  the  grass  or  a  sand  heap,  and  prefer- 
ably at  the  seashore.  In  young  children  a  slight  curvature  requires  no 
treatment;  at  least,  many  surgeons  advise  expectant  treatment  under 
such  circumstances,  awaiting  the  spontaneous  improvement  or  recovery 
produced  by  growth.     If  the  curvature  is  marked  and  the  bones  are 


STATIC  DEFORMITIES  OF  THE  K.XEE. 


641 


pliant,  it  is  better  to  correct  the  deformity  if  it  can  be  done  easily.  The 
parents  usually  request  active  treatment,  not  being  satisfied  with  the 
prospect  of  a  spontaneous  recovery,  which  can  never  be  promised  with 
certainty. 

With  sufficient  care  and  patience  even  high-grade  curvatures  can  be 
gradually  straightened  by  means  of  well-fitting  splints  or  apparatus, 
namely,  by   purely   orthopaedic    measures.      Such   apparatus   are    very 

Fig.  399. 


Modified  Thomas  knock-knee  braces  applied.      (Whitman.) 


frequently  used— mostly,  to  be  sure,  to  pacify  the  parents— and  many 
modifications  recommended,  the  details  of  which  are  superfluous  here. 
Most  of  the  apparatus,  by  means  of  bandages,  elastic  bands,  or  leather 
straps,  are  made  to  draw  the  knee  against  an  outer  strip  which  makes 
counterpressure  above  at  the  level  of  the  trochanter  and  below  at  the 
ankle.  As  such  appliances  are  effective  only  if  they  are  fixed  firmly  and 
hold  the  limb  so  that  it  cannot  be  rotated  or  flexed,  those  apparatus 
are  preferable  which  have  a  pelvic  brace  and  are  fitted  accurately  to  the 
Vol.  III.— 41 


642  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

thigh,  pelvis,  and  foot.  They  should  be  hinged  at  the  hip  and  ankle,  but 
solid  at  the  knee.  Good  apparatus  of  this  sort  are  suggested  by  Tup- 
pert,  Thomas  (Figs.  397,  398,  and  399),  Bidder,  and  others.  They  are 
only  applied  at  night  in  mild  cases;  and  in  others,  at  least  in  unilateral 
cases,  they  allow  the  patient  to  be  about  during  the  day.  Another  type 
of  apparatus  is  hinged  at  the  knee,  and  can  be  adducted  and  fastened 
at  any  angle;  it  is  made  accurately  over  a  plaster  model,  applied  in 
abduction,  and  gradually  adducted. 

Orthopaedic  treatment  to  be  successful  requires  good  apparatus,  great 
patience,  constant  attention,  and  an  ability  to  apply  the  apparatus 
properly,  essentials  which  are  often  lacking  among  the  less  educated 
classes;  the  desired  end  is  therefore  frequently  unattained,  the  apparatus 
being  worn  for  a  certain  length  of  time  and  then  thrown  aside  as  useless. 
Accordingly,  among  the  poorer  people,  the  methods  are  better  which 
do  away  with  expensive  apparatus  and  act  more  rapidly  and  energeti- 
cally. In  the  florid  stage  the  soft,  pliant  bone  can  often  be  straightened 
manually  and  held  by  means  of  a  simple  light  splint.  If  the  bone  is 
firmer,  anaesthesia  and  more  force  are  necessary;  Delore  places  the  child 
on  the  affected  side,  and  while  an  assistant  holds  the  foot  about  4  inches 
from  the  table,  makes  interrupted  pressure  with  the  hand  upon  the  inner 
side  of  the  knee  until  the  curvature  is  straightened.  This  entails  either 
an  inflexion  (infraction  or  green-stick  fracture),  or  more  frequently  a 
separation  of  the  epiphysis  of  the  femur.  Injudicious  force  can  fracture 
the  bone  at  an  undesirable  level  or  tear  the  ligaments  of  the  knee, 
especially  the  external  lateral  ligament.  A  plaster-splint  is  applied  after 
correction  has  been  effected.  If  complete  correction  is  impossible  in 
one  sitting,  a  splint  is  applied  and  the  manipulation  repeated  at  intervals 
of  two  or  three  weeks.  This  method  of  Konig  is  certain  and  without 
danger.  J.  Wolff's  method  of  repeating  the  correction  at  intervals  of 
three  days,  although  giving  excellent  results  in  very  marked  cases,  has 
the  same  danger  of  Delore's  method  if  used  too  forcibly,  or  of  Lorenz' 
correction  in  one  sitting,  namely,  that  of  stretching  or  tearing  the  liga- 
ments and  compelling  the  wearing  of  a  supporting  apparatus  for  a  year 
or  more  to  overcome  the  resulting  looseness  of  the  joint. 

If  the  bone  resists  manual  correction  and  if  spontaneous  improve- 
ment cannot  be  expected,  the  curvature  should  be  corrected  with  a 
good  osteoclast,  or  by  osteotomy  of  the  lower  end  of  the  femur 
or  the  upper  end  of  the  tibia,  according  to  the  site  of  the  greatest 
curvature. 

2.  In  adolescents  regard  for  the  etiological  factors  often  requires  a 
change  of  occupation  to  correct  the  deformity  or  prevent  its  being 
increased  by  the  injurious  influence  of  continual  standing  or  the  carrying 
of  burdens.  As  the  surgeon  is  usually  dealing  with  youthful  individuals 
who  have  been  working  for  only  a  short  time,  this  requisite  is  generally 
fulfilled  without  much  loss  to  the  patient.  Appropriate  general  treat- 
ment is  indicated,  as  in  rhachitis,  to  overcome  the  supposed  softness  of 
the  bone.  Exceptionally  it  is  necessary,  on  account  of  the  pain  at  the 
epiphysis  after  slight  exertion,  to  forbid  walking  or  standing  for  some 


STATIC  DEFORMITIES  OF  Till-:  KNEE.  643 

time,  usually  about  two  or  three  months  in  the  ease  of  pale  patients 
who  grow  rapidly  and  bave  long  hones  and  weak  nuiseles.  In  addition 
one  prescribes  phosphoric  acid,  cod-liver  oil  or  the  iron  preparations, 
baths,  and  active  massage. 

For  the  curvature  the  same  methods  are  used  as  in  the  case  of  children, 
although  the  ordinary  orthopaedic  apparatus  are  usually  only  preventive, 
not  curative.  Splints  are  not  well  home  as  they  hinder  the  patient  in 
walking  and  interfere  with  his  occupation;  to  he  of  use  they  should  he 
worn  for  years;  they  are  also  expensive.  For  this  reason  more  rapid 
correction  is  preferable  as  the  affection  occurs  chiefly  in  persons  of 
the  laboring  classes.  Konig's  manual  correction  under  anaesthesia  in 
several  sittings  and  the  application  of  a  plaster  splint  between  times 
is  advisable  for  slight  curvature;  the  splint  should  extend  from  the 
ankle  to  the  hip-joint,  preferably  including  the  foot  at  first.  Delore's 
and  Wolff's  methods  are  useful,  but  are  accompanied,  especially  the 
former,  with  the  danger  of  injury  to  the  ligaments  and  the  resulting 
loose  joint. 

The  improved  osteoclasts  which  act  more  forcibly  and  exactly  (Collin, 
Robin)  have  given  excellent  results  in  recent  years  in  the  hands  of 
German  orthopaedists  in  mild  or  moderate  cases.  All  high-grade  curva- 
tures are  treated  in  Germany  preferably  by  osteotomy.  Osteoclasis  has 
the  disadvantage  of  not  always  producing  a  transverse  fracture  at  the 
desired  point  even  with  the  best  modern  apparatus,  for  if  the  chief 
curvature  lies  in  the  upper  epiphysis  of  the  tibia  it  is  difficult  to  apply 
the  apparatus.  Furthermore,  the  apparatus  is  expensive  and  not  within 
the  means  of  every  surgeon. 

The  previous  modifications  of  osteotomy  depended  upon  the  theoretical 
view  as  to  the  site  of  the  deformity.  The  view  that  the  deformity  was 
due  to  the  difference  in  the  height  of  the  condyles  led  to  linear  or  wedge- 
shaped  osteotomv  of  the  inner  condyle;  Reeves  chiselled  off  the  condyle 
obliquely  through  a  small  incision ;  Chiene  merely  removed  a  transverse 
wedge  from  the  base  of  the  condyle,  fractured  the  rest  of  the  bone,  and 
so  drew  the  condyle  up;  Ogston's  method  of  sawing  off  the  inner  condyle 
through  a  small  incision  on  the  inner  surface  after  subcutaneous  sepa- 
ration of  the  soft  parts  from  the  bone  behind,  was  much  used;  although 
the  results  were  often  excellent,  the  method  has  been  abandoned  as  it 
opened  and  endangered  the  joint,  led  to  peroneal  paralysis,  stiffening 
of  the  joint,  and  later,  arthritis  deformans,  and  especially  because  it  did 
not  attack  the  actual  deformity  but  compensated  it  by  a  second  one. 

The  method  of  supracondylar  osteotomy  recommended  by  Macewen 
seems  without  question  to  be  the  most  rational  procedure  in  view  of 
v.  Mikulicz'  anatomical  investigations,  and  is  used  with  slight  modifica- 
tions by  most  surgeons  for  severe  cases  of  genu  valgum  adolescentium. 
Macewen  chisels  through  the  bone  through  a  small  incision  made  at 
the  point  of  junction  of  two  lines,  one  h  inch  in  front  of  and  parallel  to 
the  adductor  magnus  tendon  and  the  other  transverse  h  inch  above  the 
upper  margin  of  the  external  condyle.  An  incision  slightly  posterior  to 
this  protects  the  vastus  internus  better.    German  surgeons  usually  prefer 


644  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

a  longer  incision,  lift  off  the  periosteum  forward  and  backward,  and 
retract  the  soft  parts,  v.  Bergmann  divides  the  bone  somewhat  obliquely 
outward  and  upward  from  below.  Excision  of  a  wedge  is  rarely  neces- 
sary. Some  surgeons  chisel  through  the  bone,  others  divide  it  only 
partially  and  fracture  the  rest ;  the  latter  procedure  is  often  difficult  and 
produces  splintering  or  long  fissures.  Application  of  the  Esmarch  is  not 
essential.  A  long  incision  may  be  closed  entirely  or  partially;  drainage 
or  packing  is  generally  unnecessary.  Correction  is  usually  easy,  and 
is  maintained  by  a  long  outer  strip  or  plaster-splint. 

As  a  rule  passive  motion  of  the  joint  and  massage  may  be  begun  in 
about  four  weeks.  Recovery  is  generally  complete  in  a  few  months, 
but  not  always.  Even  when  the  process  is  entirely  aseptic  one  not 
infrequently  sees  an  effusion  in  the  joint  with  some  stiffness,  which 
requires  treatment  for  some  weeks  or  months.  To  prevent  stiffness,  the 
splint  should  always  be  removed  in  about  fourteen  days,  immobilization 
in  plaster  being  limited  to  the  absolutely  essential,  passive  movements 
being  carried  out  every  time  the  splint  is  changed.  At  the  end  of  about 
four  weeks  the  splint  should  be  taken  off  every  two  or  three  days,  the 
joint  and  muscles  massaged,  and  the  knee  exercised  passively.  This 
after-treatment  is  facilitated  by  using  a  plaster-strip  splint  applied 
directly  to  the  skin. 

Another  undesirable  result  of  the  operation  is  an  awkward  bayonet 
deformity  of  the  limb.  The  abduction  is  overcome,  but  after  some  time 
the  leg  is  shifted  inward  on  the  thigh;  this  is  most  liable  to  occur  if  the 
division  is  made  a  trifle  too  high  on  the  lower  end  of  the  femur.  This 
deformity  is  unavoidable  if  the  femur  alone  is  divided  when  the  curvature 
is  severe  and  involves  both  the  tibia  and  femur.  For  this  reason  it 
would  be  a  mistake  to  limit  the  correction  to  the  femur  in  severe  cases, 
although  in  the  great  majority  supracondylar  osteotomy  is  sufficient. 

"  Infracondylar"  osteotomy  (below  the  tuberosities)  of  the  tibia  is 
therefore  necessary  in  addition  if  the  curvature  in  the  tibia  is  equal  to 
or  more  pronounced  than  that  of  the  femur.  In  contrast  to  the  opera- 
tion on  the  femur,  the  removal  of  a  wedge  from  the  inner  side  is  almost 
always  necessary.  Through  a  longitudinal  or  transverse  incision  the 
periosteum  is  lifted  off  and  the  bone  chiselled  either  entirely  through 
or  far  enough  to  be  broken  easily;  exceptionally,  linear  osteotomy  of  the 
fibula  below  the  head  is  necessary.  Schede  recommends  dividing  the 
fibula  first,  but  it  is  certainly  an  advantage  if  this  can  be  avoided, 
as  the  peroneal  nerve  may  be  injured  or  become  enclosed  in  the  callus 
later. 

The  very  severe  cases  of  genu  valgum  in  adults  in  which  there  is 
hyperextension  and  outward  rotation  of  the  leg  due  to  the  loosening  of 
the  ligaments  are  not  benefited  by  osteotomy,  particularly  if  arthritis 
deformans  has  already  developed.  If  under  these  circumstances  the 
often  very  marked  disability  of  the  patient  demands  operative  inter- 
ference, typical  resection  of  the  joint  is  the  last  resort.  The  resulting 
ankylosis  may  transform  the  cripple  into  an  individual  able  to  work,  at 
least  if  the  affection  is  unilateral. 


.STATIC  DEFORMITIES  OF  THE  KNEE. 


645 


Genu  Varum  (O-Bein,  Bow-legs).— Genu  varum,  the  reverse  of 
genu  valgum,  in  the  large  majority  of  eases  is  the  result  of  rhachitis  in 
childhood,  although  occasionally,  like  genu  valgum  adolescentium,  but 
much  less  frequently,  it  appears  first  at  puberty.  This  etiology  corre- 
sponds to  the  form  of  the  curvature  as  well  as  to  the  frequency  with 
which  it  is  bilateral.  The  same  deflexion  of  the  epiphysis  on  the  shaft 
occurs  as  in  genu  varum,  but  in  the  opposite  direction  and  more  fre- 
quently in  the  tibia  than  the  femur.  The  shaft  is  usually  involved  to 
some  extent  in  the  curvature.  Other  signs  of  recent  or  past  rhachitis 
are  usually  present  in  the  lower  extremities,  especially  curvatures  of  the 


Fig.  400. 


Fig.  401. 


Genu  varum  type  of  bow-legs,  showing  the  out- 
ward rotation  of  the  femora.     (Whitman.) 


Long  braces  for  genu  varum.     (Bradford 
and  Lovett.) 


lower  part  of  the  leg  convex 
forward,  and  rhachitic  flat- 
foot.  The  foot  is  turned  in- 
ward slightly,  sometimes  greatly 
by  the  inward  torsion  of  the  tibia. 
Occasionally  there  is  varum  of 
one  knee  and  valgum  of  the  other. 
The   curvature  may  be   very 


great  in  children;  in  the  rare  cases  in  adolescence  it  is  the  exception. 
Whereas  in  children  genu  valgum  may  improve  with  growth,  or  even 
disappear,  genu  varum,  once  established,  is  little  influenced  by  growth. 
As  a  rule  extension  is  somewhat  limited,  otherwise  the  function  of  the 


646  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

joint  is  not  much  impaired.  It  is  only  in  the  very  severe  cases,  the 
same  as  in  genu  valgum,  that  arthritic  processes  sometimes  gradually 
develop  and  diminish  the  earning-efficiency  of  the  patient. 

Treatment. — The  treatment  is  the  same  as  that  of  genu  valgum, 
namely,  gradual  straightening  by  means  of  orthopaedic  apparatus, 
Delore's  method  of  separating  the  epiphysis,  Lorenz'  "moulding" 
method,  Wolff's  correction  in  stages  by  means  of  plaster-splints,  forcible 
correction  in  several  sittings,  or  open  osteotomy.  As  spontaneous 
recovery  by  growth  is  not  to  be  expected,  interference  is  necessary  earlier 
than  in  genu  valgum.  Of  the  orthopaedic  apparatus  used:  the  inner 
strip  splint  is  usually  unstable  and  unsatisfactory;  an  outer  splint  well 
padded  at  the  knee  and  bound  to  the  thigh  and  pelvis  is  made  to  exert 
lateral  traction  on  the  leg;  inner  and  outer  splints  are  often  used  together. 
An  outer  splint  of  spring  metal  is  also  used,  exerting  steady  elastic 
traction  on  the  leg. 

Correction  under  anaesthesia  and  the  application  of  a  plaster  splint 
are  preferable  to  treatment  by  means  of  apparatus  for  the  same  reasons 
that  apply  in  genu  valgum.  If  operation  is  indicated  for  severe  curvature 
associated  with  hardness  of  the  bones,  it  will  usually  be  directed  to  the 
upper  end  of  the  leg,  namely,  division  of  the  tibia  and  as  a  rule  of  the 
fibula.  On  account  of  the  elasticity  of  the  fibula  it  will  be  better  to 
divide  it  first,  making  the  division  below  the  head  and  guarding  the 
peroneal  nerve.  Linear  osteotomy  is  usually  sufficient;  exceptionally  a 
wedge  of  bone  has  to  be  removed.  In  severe  cases  the  curvatures  so 
often  present  simultaneously  elsewhere  have  to  be  corrected  in  several 
operations. 


TUMORS  IN  AND  ABOUT  THE  KNEE-JOINT. 

Of  the  tumors  of  the  ends  of  the  bones,  exostosis  is  the  most  common. 
(Fig.  402.)  It  usually  starts  near  the  epiphyseal  line  of  the  femur  or 
the  tibia,  is  similar  to  the  spongiosa  in  structure,  and  is  covered  with 
cartilage  (cartilaginous  exostosis).  Bony  tumors  covered  only  with 
connective  tissue  are  generally  to  be  regarded  as  osteophytes  of  inflam- 
matory origin — for  example,  from  an  adjacent  osteomyelitis  or  after 
fracture.  The  frequent  small  exostoses  of  rhachitis  were  mentioned 
under  Genu  Valgum.  Cartilaginous  exostoses  are  due  to  a  maldevelop- 
ment  which  is  hereditary  in  certain  families;  instances  are  known  in 
which  almost  all  the  children  showed  exostoses.  The  so-called  exostosis 
bursata,  a  rare  affection  of  the  knee,  is  interesting;  it  is  a  broad-based 
bony  growth  covered  with  cartilage,  springing  from  the  end  of  the  bone 
and  having  a  bursa  over  it  containing  one  or  more  or  even  hundreds  of 
free  cartilaginous  bodies.  (Cases  of  Billroth  and  Rindfleisch,  v.  Berg- 
mann  and  Fehleisen,  v.  Volkmann,  Riethus.)  Chondroma  belongs  to 
the  same  group;  it  is  occasionally  found  symmetrically  on  the  joint- 
surfaces  of  both  knees  associated  with  multiple  chondromata  of  the 
hands  and  feet.     The  majority  of  pure  bony  or  cartilaginous  tumors 


Ti'Mons  i.x  am)  Miorr  rui-:  kske  joizt. 


047 


can  be  left  undisturbed,  as  they  cause  no  trouble  unless  large  or  pecu- 
liarly situated,  in  which  ease  they  are  removed. 

The  malignant  osseous  tumors,  although  rare,  are  more  important 
practically,  namely,  the  myelogenous  and  periosteal  sarcomata  occurring 
chiefly  in  adolescents  or  well-developed  adults.  They  are  giant-cell, 
spindle-cell,  or  large  or  small  round-cell  sarcomata.  The  favorite  site 
of  myeloid  sarcoma  is  the  lower  end  of 
the  femur  or  the  upper  end  of  the  tibia; 
the  tumor,  centrally  situated  and  "bal- 
looning" out  the  thin  covering  of  bone,  is 
soft  in  the  centre  or  traversed  by  a  wide- 
meshed  framework  of  spongy  bone. 
Gradually  pushing  the  bone  before  it,  it 
advances  up  to  the  cartilage  of  the  joint, 
but  often  exists  for  a  long  time  before 
breaking  through  the  latter;  meanwhile 
it  attacks  the  ligaments,  especially  the 
crucial  ligaments,  advances  into  the 
joint,  rapidly  producing  effusion,  and  at 
first  a  circumscribed,  later  a  diffuse  sar- 
coma of  the  capsule.  The  diagnosis  is 
easy  if  the  tumor  is  very  large  or  dis- 
tinctly limited  to  a  condyle  without  in- 
volving the  joint;  in  most  of  the  cases, 
however,  a  diagnosis  is  impossible.  The 
dull  pain,  the  moderate  swelling  at  the 
outset,  and  the  effusion  in  the  joint  are 
generally  mistaken  for  those  of  a  chronic 
inflammation,  usually  tuberculosis,  and 
the  true  character  of  the  tumor  only  dis- 
covered later  or  by  operation. 

Myeloid  giant-cell  sarcoma  is  rela- 
tively benign,  not  attaining  any  consid- 
erable size  until  after  several  years; 
large-cell  and  small-cell  round-cell  sar- 
comata are  generally  very  malignant.  The  giant-cell  variety  is  there- 
fore often  removable  by  conservative  operation,  resection  of  the  joint 
or  joint-surfaces,  or  even  thorough  scraping  and  cauterization  of  the 
tumor  cavity  and  packing,  (v.  Volkmann,  v.  Bergmann,  Rosen- 
berger,  and  others.)  A  number  of  cases  are  reported  in  which  these 
methods  wrere  without  recurrence  after  several  years.  On  the  other 
hand,  spindle-  and  round-cell  sarcomata,  especially  of  the  periosteum, 
call  for  early  high  amputation  of  the  limb.  If  the  tumor  is  not 
limited  to  the  tibia  or  the  lower  epiphysis  of  the  femur,  exarticula- 
tion  at  the  hip-joint  is  usually  preferable  to  high  amputation,  as  the 
medulla  of  the  femur  is  often  involved  early  and  high  up.  Neverthe- 
less in  a  case  of  periosteal  sarcoma  of  the  lower  end  of  the  femur  in 
which  v.  Mikulicz  resected  S  inches  of  bone  there  was  no  recurrence  at 


Exostoses  of  the  lower  epiphysis  of 
the  femur  and  of  the  upper  epiphysis 
of  the  tibia. 


648 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


the  end  of  a  year.     Such  favorable  results  are  too  infrequent,  however, 
to  affect  the  preceding  rule. 

Purely  intra-articular  tumors  are  very  rare;  the  free  bodies  in  arthritis 
deformans  are  not  classified  as  neoplasms.  Lipoma  arborescens, 
already  mentioned,  is  a  rare,  more  or  less  diffuse  hyperplasia  of  part  of 
the  villi  accompanied  by  fatty  degeneration.  (Fig.  403.)  As  a  rule 
the  growth  consists  of  a  number  of  more  or  less  dendritic  fat-lobules 
having  a  connective  tissue  ground  substance.  Tubercles  have  been 
found  in  a  few  cases,  but  in  a  number  of  others  the  growth  was  cer- 
tainly not  tuberculous.  (Gotz,  Sokoloff,  Stieda,  Israel.)  On  the  con- 
trary, the  growth  apparently  occurs  with  the  most  diverse  chronic 
inflammations  of  the  joint.  A  diagnosis  before  incision  is  only  excep- 
tionally possible  by  the  palpation  of  a  soft  lobulated  tumor  and  soft 
crepitus  during  motion.     (Fig.  403.) 

Fig.  403. 


Lipoma  arborescens  of  the  knee-joint,     (v.  Bruns.) 


Pedunculated  lipomata,  single  or  multiple,  are  even  more  rare  and 
are  supposed  to  originate  ordinarily  in  the  thick  subsynovial  adipose 
tissue,  especially  at  the  sides  of  the  ligamentum  patellae.  Konig  con- 
ceives that  it  grows  into  the  joint  through  a  traumatic  cleft  in  the  synovi- 
alis.  Lauenstein,  Wagner,  and  others  accept  this  hypothesis.  Some 
authors  regard  its  derivation  from  the  villi  as  possible.  (Otterbeck, 
Filter.)     Otterbeck  records  a  lipoma  lying  entirely  free  in  the  joint. 

Genuine  fibroma  also  occurs  in  the  knee-joint.  Mayo  Robson  saw  a 
sailor  who  two  years  previously  had  suffered  a  contusion  of  the  knee 


DISEASES  OF  THE  B  URS^E  OF  THE  KNEE.  649 

and  gave  symptoms  of  an  intra-articular  foreign  body;  three  broad- 
based  fibromata  of  the  size  of  a  hazelnut,  walnut,  and  hen's  egg  were 
found  attached  to  the  synovialis.  Cartilaginous  and  bony  tumors  are 
occasionally  found;  v.  Volkmann  cites  an  interesting  case  of  exostosis 
bursata.  The  author  reported  a  case  of  diffuse  chondroma;  the  entire 
synovialis  was  diseased  and  transformed  in  places  into  plates  of  car- 
tilage '.  to  1  inch  in  thickness.  Garre  records  a  diffuse  sarcoma  of  the 
synovialis,  but  it  is  questionable  whether  this  was  primary  in  the 
synovialis  or  came  from  an  extra-articular  myeloid  sarcoma. 

The  symptoms  of  intra-articular  tumors  are  usually  indefinite  and 
resemble  those  of  free  bodies;  but  the  attacks  of  pain  are  less  severe. 
Occasionally  the  tumor  has  been  felt  distinctly  and  diagnosed  before 
operating.     The  treatment  is  extirpation. 

The  neoplasms  originating  infrequently  in  the  soft  parts  about  the 
knee-joint  are  of  little  interest;  they  are  mostly  fibroma,  myxoma,  or 
sarcoma  starting  in  the  skin  or  fascia.  Lipoma  of  the  subcutaneous 
adipose  tissue  is  rare;  in  the  popliteal  space  it  may  be  confused  with 
an  abscess  or  cyst.  A  relatively  large  number  of  tumors  originate  in 
the  numerous  bursa?  of  the  knee,  especially  the  prepatellar;  fibroma, 
chondroma,  and  osteoma,  even  as  large  as  a  walnut  or  hen's  egg,  have 
been  reported.  The  author  saw  2  cases  in  which  a  movable  tumor, 
lying  upon  the  patella,  of  almost  bony  hardness  and  the  size  of  a  small 
hen's  egg,  proved  on  excision  to  be  a  fibrous  degeneration  of  the  bursa. 
In  such  instances  it  may  be  difficult  to  differentiate  between  a  chronic 
inflammation  and  neoplasm.  In  other  cases  the  tumor  was  solid  and 
recognized  as  a  fibroma,  chondroma,  osteoma,  sarcoma,  or  myxoma, 
v.  Mikulicz  saw  a  carcinoma  develop  from  a  fistula  of  the  bursa. 
Lejars  reports  a  case  of  osteoma  of  the  ligamentum  patellae. 

The  symptoms  depend  chiefly  upon  the  size  and  situation  of  the 
tumor;  as  a  rule  tumors  over  the  patella  are  only  troublesome  in  kneel- 
ing; those  situated  deeper — for  example,  in  the  subpatellar  bursa  or  in 
the  popliteal  space — hinder  motion  more  or  less.  Pressure  upon  the 
sciatic  nerve  may  produce  sciatic  pains  or  paralysis;  pressure  upon  the 
popliteal  vessels,  congestion  in  the  area  of  the  saphenous  vein  and 
oedema  of  the  foot  and  leg.  Such  disturbances  develop  more  frequently 
and  earlier  in  connection  with  rapidly  growing  malignant  sarcoma  than, 
for  example,  with  diffuse  lipoma,  although  they  have  been  observed 
with  the  latter.  The  diagnosis  is  according  to  the  general  rules  applying 
to  tumors;  in  the  popliteal  space  one  should  always  think  of  aneurism 
of  the  popliteal  artery,  especially  if  the  tumor  pulsates.  (See  Popliteal 
Aneurism.) 

DISEASES  OF  THE  BURS^I  OF  THE  KNEE. 

The  diseases  of  the  numerous  bursa?  about  the  knee  are  entirely 
analogous  to  those  of  the  synovialis  of  the  joint;  one  observes  there- 
fore acute  serous,  acute  purulent,  chronic  serous  inflammation  with 
or  without  proliferation  of   the  synovialis,  and   primary  or  secondary 


650  DISEASES  IN  AXD  ABOUT  THE  KSEE-JOIXT. 

tuberculosis.  The  bursse  connecting  with  the  joint  are  naturally 
included  in  the  processes  of  the  latter;  this  applies  particularly  to  the 
upper  recess  or  subcrural  bursa  and  to  the  popliteal  bursa,  which  com- 
municate most  frequently  with  the  joint.  Independent  of  such  joint- 
affections  the  prepatellar  bursse  are  the  ones  most  frequently  diseased 
primarily;  of  the  three  bursse  known,  one  lies  directly  beneath  the  skin, 
another  between  the  fascia  and  the  aponeurosis  radiating  from  the 
vastus  tendon,  and  the  third  between  the  aponeurosis  and  the  patella; 
they  are  not  all  constant,  often  only  two  are  found;  they  may  communi- 
cate. 

Acute  Prepatellar  Bursitis. — Acute  prepatellar  bursitis  usually  fol- 
lows an  injury  or  inflammation — for  example,  a  furuncle  situated  over 
the  bursa;  less  frequently  it  is  the  result  of  direct  injury  of  the  bursa 
and  infection  of  the  effusion  of  blood.  The  involvement  of  the  over- 
lying soft  parts  obscures  the  outline  of  the  distended  bursa.  But  the 
fluctuating,  tense  and  hemispherical  tumor  can  always  be  felt  in  front 
of  the  patella,  and  the  diagnosis  of  acute  serous  bursitis  is  thus  easily 
made  by  the  absence  of  fever,  with  or  without  slight  limited  redness  of 
the  skin,  and  the  slight  local  tenderness.  Suppurative  bursitis  gives 
the  signs  of  a  prepatellar  phlegmon;  the  redness  and  oedematous  swell- 
ing sometimes  extend  in  all  directions,  and  at  first  glance  suggest  an 
acute  inflammation  of  the  joint,  especially  as  there  are  usually  fever  and 
great  pain  on  motion.  Careful  palpation  shows  that  the  fluctuation 
is  in  front  of  the  patella  and  without  ballottement  of  the  latter;  it  may 
be  that  the  joint  has  become  involved  secondarily — acute  synovitis — by 
the  periarticular  inflammation. 

Treatment. — The  acute  serous  inflammation  subsides  in  a  few  days 
after  removing  the  cause — incising  the  furuncle,  etc. — either  with  the 
aid  of  rest  and  wet  dressings  or  spontaneously.  If  not  protected  suf- 
ficientlv,  it  is  apt  to  become  chronic  but  without  producing  any  further 
disturbance.  Suppurative  bursitis  requires  free  incision  and  scraping, 
or,  better,  total  excision  of  the  bursa;  in  either  case  the  cavity  should  be 
packed  for  a  few  days  and  the  wound  closed  secondarily  after  freshening 
up  the  edges. 

Chronic  Prepatellar  Bursitis. — Chronic  serous  prepatellar  bursitis 
is  most  frequently  due  to  the  irritation  produced  by  kneeling.  It  is 
therefore  seen  most  commonly  in  people  whose  occupation  compels 
them  to  kneel  a  great  deal  (housemaid's  knee).  The  contention  that 
the  front  of  the  patella  does  not  touch  the  floor  while  kneeling  does  not 
apply,  as  the  patients  concerned — for  example,  scrubwomen — usually 
have  to  lean  forward  in  their  work.  The  constant  irritation  produces 
thickening  of  the  wall  of  the  bursa  and  exudation  of  a  pure  synovial,  or 
if  it  contains  blood,  a  thin  yellowish  or  reddish  or  brownish  fluid.  The 
thickness  of  the  walls  and  the  amount  of  fluid  vary  considerably;  the 
cystic  tumor  may  reach  the  size  of  a  hen's  egg  or  fist,  and  extend  later- 
ally beyond  the  patella  so  that  the  underlying  capsule  may  be  injured 
in  excising  the  bursa.  If  it  has  existed  for  years,  there  are  almost 
alwavs  circumscribed,  dense,  fibrous,  occasionally  branched,  villiform 


DTSEASES  OF  THE  BURSJE  OF  THE  KNEE.  651 

growths,  from  T1T  to  /.  inch  in  diameter  and  I  to  1  inch  long,  projecting 
from  the  synovialis  into  the  cavity  or  stretched  between  the  walls!  This 
form  is  termed  bursitis  proliferans  in  contrast  to  the  simple  serous 
variety. 

Symptoms. — The  symptoms  are  usually  slight;  often  they  are  absent, 
and  the  attention  of  the  patient  is  first  called  to  the  long-existing  affec- 
tion by  an  acute  exacerbation;  in  kneeling  particularly  a  slight  tender- 
ness is  complained  of.  The  chief  symptom  is  the  presence  of  a  circum- 
scribed, distinctly  fluctuating  tumor  beneath  the  normal  skin  and  in 
front  of  the  patella. 

Treatment. — The  treatment  of  chronic  bursitis  consists  in  aspirating  the 
contents  of  the  cavity,  washing  it  out  with  3  per  cent,  carbolic  acid  solu- 
tion, or  injecting  5  or  6  c.c.  of  10  per  cent,  iodoform  glycerin  after  aspir- 
ating; especially  the  latter  has  repeatedly  given  the  author  good  results; 
painting  with  tincture  of  iodine  is  useless.  The  limb  is  placed  extended 
in  a  tin  or  other  light  splint  for  about  six  days  under  moderate  pressure; 
later,  compression  and  the  use  of  wet  compresses  at  night  must  be  con- 
tinued for  some  time,  possibly  the  aspiration  and  injection  repeated. 
The  patient  is  not  allowed  to  get  up  until  several  days  after  the  swelling 
has  entirely  disappeared.  If  one  desires  to  prevent  recurrence  and  is 
sure  of  his  asepsis,  free  incision  and  scraping  followed  by  drainage,  or, 
better,  total  excision,  is  preferable;  the  incision  may  be  longitudinal 
over  the  most  prominent  part  of  the  tumor  or  curved,  convex  upward, 
over  the  upper  half.  Under  application  of  the  Esmarch  and  with 
asepsis  the  operation  is  simple  and  harmless;  drainage  is  unnecessary. 
The  apposition  of  the  edges  of  the  wound  should  be  exact  to  prevent  a 
troublesome  cicatrix.  Active  work  should  not  be  resumed  till  the 
fourth  week.  Bursitis  proliferans  demands  operation;  extirpation,  or 
free  incision,  and  removal  of  the  villi.  The  latter  can  be  felt  previous 
to  operation  as  nodular  and  cord-like  thickenings,  which  can  be  rolled 
under  the  fingers  against  the  underlying  patella. 

Tuberculous  Prepatellar  Bursitis.— Tuberculous  prepatellar  bursitis 
occurs  primarily  or  secondary  to  a  tuberculous  focus  in  the  patella;  fluc- 
tuation is  either  less  distinct  than  in  serous  bursitis  or  is  absent.  The 
wall  of  the  bursa,  greatly  thickened  by  the  tuberculous  granulations,  feels 
like  the  margin  of  the  upper  recess  in  tuberculosis  of  the  joint.  The 
discomfort  is  greater,  pressure  is  often  very  painful.  The  only  proper 
treatment  is  excision  of  the  bursa  and  eventually  extirpation  of  the 
focus  in  the  patella,  particularly  if  the  joint  is  intact. 

Bursitis  Praetibialis. — The  pretibial  bursa  lower  down  between  the 
fascia  and  tibial  spine  is  subject  to  the  same  diseases  and  gives  the 
same  symptoms  as  the  prepatellar  bursa,  except  that  the  tumor  is  situ- 
ated below  the  patella  and  in  front  of  its  ligament.  If  the  bursa  com- 
municates with  the  prepatellar  bursa,  the  tumor  extends  from  the  upper 
border  of  the  patella  to  the  tibial  spine. 

Bursitis  Xnfragenualis. — The  infrapatellar  or  infragenual  bursa, 
situated  in  the  adipose  tissue  between  the  lower  half  of  the  patellar 
ligament   and   the   front   margin    of   the  tibia,  is  affected   much    less 


652 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


Fig.  404. 


frequently.  But  on  account  of  its  position  it  produces  immediate 
functional  disturbance;  active  extension  and  flexion  are  limited  in 
direct  relation  to  the  size  and  tension  of  the  tumor.  With  even  a  mod- 
erate effusion  the  bursa  projects  at 
both  sides  of  the  patellar  ligament, 
obliterating  the  normal  depressions 
or  even  bulging  and  giving  a  char- 
acteristic through-fluctuation  be- 
neath the  patellar  ligament  but  with- 
out ballottement  of  the  patella.  As 
the  bursa  seldom  communicates  with 
the  joint,  even  a  purulent  inflam- 
mation, acute  or  chronic  — as,  for 
example,  from  a  tuberculous  focus 
in  the  head  of  the  tibia — may  be 
limited  to  the  bursa  and  by  timely 
operation  recover  without  involving 
the  joint.  If  a  serous  bursitis  does 
not  yield  rapidly  after  applying  im- 
mobilization, moist  heat,  and  press- 
ure, the  effusion  should  be  aspi- 
rated and  the  bursa  washed  out  with 
carbolic  acid  or  iodoform-glycerin 
injected;  suppuration  demands  free 
incision  and  packing;  if  tuberculous, 
excision  of  the  bursa  and  extirpation 
of  the  primary  osseous  focus. 

Of  the  lateral  bursa?,  the  bursa 
bicipitis  and  bursa  anserina  are  the 
ones  most  apt  to  be  affected  in 
consequence  of  trauma,  gonorrhoea, 
syphilis,  and  tuberculosis.  Their 
superficial  position  facilitates  the 
diagnosis. 

Popliteal  Cysts. — Serous  inflam- 
mation of  the  bursa?  back  of  the 
joint  gives  rise  to  the  so-called  pop- 
liteal cysts,  which  vary  in  size  from 
that  of  a  hazelnut  to  that  of  a  fist. 
The  smaller  cysts  usually  escape 
detection  on  account  of  their  deep 
situation.  The  bulging  of  the  cyst 
is  best  recognized  with  the  knee  ex- 
tended; in  flexion  the  tumor  disap- 
pears, but  as  a  rule  is  then  felt  more  easily. 

An  hygroma  of  the  bursa  semimembranosa  usually  forms  an  egg- 
shaped  tumor  in  the  inner  half  of  the  popliteal  space;  an  hygroma  of 
the  popliteal  bursa  situated  between  the  strong  tendon  of  the  popliteus 


Popliteal  cysts  originating  in  the  popliteal 
bursa.  1.  Larger  part  of  the  cystic  mass  be- 
tween the  soleus  muscle  (2}  and  the  inter- 
osseous ligament.  1'.  Pedicle  of  the  mass 
lying  under  the  popliteus  muscle  (3)  divided 
transversely.      (Poirier.) 


DISEASES  OF  THE  BURS.E  OF  THE  KNEE.  653 

muscle,  the  posterior  outer  surface  of  the  tibia,  and  the  head  of  the 
fibula,  lies  in  the  outer  half  of  the  popliteal  space.  According  to  I'oirier, 
other  cysts  develop  from  protrusions  of  the  synovialis  between  the 
origins  of  the  gastrocnemii  above  the  condyles.  (Fig.  404.)  CJiron 
saw  and  excised  an  unusually  large  popliteal  cyst  which  did  not  com- 
municate with  the  joint,  and  which  extended  from  the  middle  third  of 
the  thigh  to  the  level  of  the  muscles  of  the  calf. 

The  disturbance  produced  is  usually  limited  to  a  feeling  of  tension 
behind  the  knee  which  increases  to  actual  pain  on  exertion,  easy  fatigue 
in  walking — especially  in  climbing  stairs — and  impairment  of  active 
and  passive  flexion  of  the  joint.  Occasionally  the  annoying  feeling  of 
tension  makes  sitting  for  any  length  of  time  impossible  and  impairs  the 
earning-efficiencv  of  the  patient. 

Diagnosis. — The  diagnosis  depends  upon  evidence  of  the  presence  of 
a  cystic  tumor,  namely,  a  circumscribed,  fluctuating  swelling,  round  or 
oval,  painless  or  only  slightly  sensitive,  pedunculated  and  movable,  or 
immovable,  with  a  deeply  situated  broad  base.  Aneurism,  soft  sarcoma, 
myxoma,  lipoma,  and  especially  cold  abscesses,  are  to  be  excluded. 
The  diagnosis  is  facilitated  by  the  symptoms  of  a  hydrarthrosis  added  to 
those  of  a  popliteal  cyst,  if  the  bursa  communicates  with  the  joint — the 
rule  with  the  popliteal  bursa,  less  frequent  in  the  case  of  the  bursa 
semimembranosa.  Through-fluctuation  between  the  joint  and  the 
cyst  can  then  usually  be  felt  distinctly. 

Prognosis. — The  prognosis,  as  in  chronic  hydrarthrosis,  is  not  entirely 
favorable  in  that  conservative  treatment  takes  a  long  time,  the  tendency 
to  recurrence  is  great,  and  the  removal  of  the  tumor,  deeply  situated 
and  close  to  important  nerves  and  vessels,  is  difficult,  and  is  not  always 
successful  if  the  walls  are  thin  and  easily  torn. 

Treatment. — The  treatment  consists  in  aspirating  and  washing  out 
the  cyst  and  immobilizing  the  limb  upon  a  well-padded  splint.  Effect- 
ual pressure  is  impossible  on  account  of  the  danger  to  the  popliteal 
vessels.  Injection  of  tincture  of  iodine,  formerly  widely  recommended, 
easily  produces  an  undesirable  inflammation,  and  is  therefore  con- 
traindicated  on  account  of  the  danger  of  secondary  inflammation  of 
the  joint.  Injection  of  iodoform-glycerin  is  less  harmful  and  often 
effectual. 

If  not  effectual,  extirpation  under  application  of  the  Esmarch  and  with 
strict  asepsis  is  indicated.  As  stated,  this  is  a  difficult  procedure,  but 
has  given  the  best  results.  If  total  excision  is  impossible,  the  remaining 
parts  of  the  cyst  can  be  swabbed  out  with  3  per  cent,  carbolic  acid 
solution  and  packed  or  drained. 

Small  cystic  tumors  of  the  size  of  a  hazelnut  or  walnut  and  filled  with 
a  synovia-like  fluid  have  been  found  at  points  about  the  joint  not  corre- 
sponding to  the  site  of  the  typical  bursa?  and  described  as  ganglia; 
their  origin  is  not  explained;  they  are  variously  regarded  as  irregular 
protrusions  of  the  synovialis,  or  crypts  in  the  subsynovialis — Poirier 
does  not  recognize  the  distinction  made  between  synovial  hernias  and 


654  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

subsynovial  crypts — or  atypical  bursa?,  or  products  of  mucoid  degenera- 
tion of  adipose  tissue.  (Ledderhose.)  If  troublesome,  their  treatment 
is  the  same  as  that  of  bursitis. 


ABSCESSES  OF  THE  POPLITEAL  SPACE. 

Abscesses  in  the  popliteal  space  may  be  due  to  suppuration  of  the 
glands  in  that  region.  The  glands  in  the  popliteal  space  are  sometimes 
swollen  in  connection  with  inflammatory  processes  in  the  toes  or  foot, 
but  much  less  often  than  the  inguinal  glands.  This  swelling  subsides 
rapidly  even  without  wet  dressings  being  applied  if  the  primary  focus 
is  treated  in  time.  If  the  glands  suppurate,  a  periadenitis  ensues  rapidly. 
The  contour  of  the  glands,  which  are  of  the  size  of  a  hazelnut  or  walnut, 
is  easily  recognizable  at  first,  but  later  becomes  lost  in  a  diffuse,  tender, 
firm  and  then  doughy  swelling,  filling  the  popliteal  space,  later  giving 
fluctuation  in  the  centre;  the  overlying  skin  becomes  reddened,  the  joint 
is  held  slightly  flexed  and  motion  anxiously  avoided;  the  picture  is 
similar  to  that  of  the  more  frequent  axillary  adenitis. 

In  other  instances  the  abscess  is  due  to  inflammation  of  a  varix  of 
the  saphenous  vein  or  to  small  circumscribed  foci  of  osteomyelitis  or 
periostitis  in  the  lower  end  of  the  femur.  The  abscess  is  then  deeply 
situated  in  contrast  to  the  first  variety.  The  onset  may  be  rapid  with 
high  fever  and  mental  disturbances;  usually  several  days  elapse  before 
the  swelling  and  redness  become  distinct;  only  the  severe  pain  indicates 
approximately  the  site  of  the  affection.  Then  the  symptoms  become 
more  distinct,  usually  accompanied  by  moderate  oedema  of  the  leg; 
finally  fluctuation  can  be  felt.  Occasionally  the  signs  of  acute  inflam- 
mation subside  after  a  short  time  and  the  pain  diminishes;  later,  in 
several  weeks  or  even  months,  an  abscess  develops,  and  on  incision  a 
small  free  cortical  sequestrum  is  found  at  the  bottom.  From  the  etiology 
it  is  clear  that  this  deep  acute  suppuration  may  be  accompanied  by 
inflammation  of  the  joint.  Suppuration  of  an  aneurism  is  rare  but 
should  be  remembered. 

Of  the  chronic  suppurations  should  be  mentioned  tuberculous  adenitis, 
cold  abscesses  from  small  osseous  foci  or  from  a  bursitis,  and  syphilitic 
ulceration  of  the  skin  and  glands. 

Treatment. — The  treatment  of  all  these  affections  is  on  general  prin- 
ciples. As  soon  as  pus  is  suspected  incision  and  drainage  are  indicated; 
the  proximity  of  the  large  vessels  and  nerves  demands  careful  dissection, 
the  skin  being  incised  freely  and  retracted.  The  possible  subsequent 
cicatricial  contraction  should  be  combated  by  means  of  a  strip  or  exten- 
sion splint,  and  if  there  are  extensive  defective  areas  of  skin,  by  grafting 
early. 

POPLITEAL  ANEURISM. 

Traumatic  aneurism  of  the  popliteal  artery  is  rare;  spontaneous 
aneurism    relatively   frequent,    constituting   a    third    of   all    peripheral 


PLATE  XVI 


tgf~~- 


Aneurism  of  the  Popliteal  Artery.     (Jacob.) 


POPLITEAL  ANEURISM.  655 

aneurisms.  The  cause  is  atheroma  or  syphilis.  Why  the  popliteal 
artery  should  be  a  favorite  spol  is  not  entirely  explained;  it  has  not 
been  proved  thai  the  fixation  of  the  vessel  in  Hunter's  canal  and  in  the 
tendon  of  the  soleus  increases  the  Liability  to  tearing  in  forced  extension 
or  flexion,  although  it  is  certain  that  continuous  hard  labor  predisposes 
to  the  production  of  an  aneurism.  The  dilatation  of  the  vessel  may 
occur  at  any  point,  above,  below,  in  the  middle,  in  front,  or  behind; 
rarely  it  involves  the  vessel  throughout  its  entire  extent.  The  growth 
is  generally  rapid,  exceptionally  coming  to  a  standstill  after  reaching  a 
certain  size.  As  it  enlarges  the  veins  and  nerves  are  pushed  aside  and 
compressed;  soon  it  projects  as  a  pulsating  tumor  in  the  popliteal  space, 
stretches  the  skin,  becomes  adherent  to  it,  and  may  rupture  outward 
or  beneath  the  fascia.  In  the  latter  case  the  extravasation  infiltrates 
the  tissues  and  by  pressure  upon  the  vessels  easily  causes  gangrene  of 
the  leg.  Advancing  forward,  the  tumor  may  perforate  into  the  joint  or 
erode  one  of  the  condyles.  Arteriovenous  aneurisms,  either  aneurismal 
varix  or  varicose  aneurism,  of  the  popliteal  are  rare. 

Symptoms. — The  symptoms  of  aneurism  at  the  outset  are  slight, 
merely  a  feeling  of  tension  and  some  limitation  of  flexion  and  extension 
of  the  knee.  The  tense  feeling  increases  slowly  or  rapidly  to  actual 
pain,  radiating  in  to  the  leg  and  foot  and  accompanied  by  paresthesias 
and  paresis;  actual  paralysis  is  exceptional.  These  disturbances  are 
partly  the  result  of  direct  pressure  upon  the  tibial  or  peroneal  nerve, 
partly  the  result  of  the  venous  stasis,  the  latter  being  manifested  by 
cyanosis  and  oedema  of  the  foot  and  leg.  The  circulatory  disturbance 
not  infrequently  increases  to  the  production  of  partial  or  complete 
gangrene. 

The  typical  symptoms  in  addition  to  the  above  disturbances  are  the 
development  of  a  circumscribed  tumor  pulsating  in  all  directions — in 
contrast  to  the  transmitted  pulsation  of  tumors  lying  on  the  popliteal 
artery — cessation  of  the  pulsation  on  compressing  the  femoral  artery, 
exaggeration  of  the  same  by  circular  compression  of  the  leg  below  the 
tumor,  and  a  blowing  or  rasping  murmur  heard  over  the  tumor.  If  the 
sac  communicates  with  the  artery  by  a  narrow  opening  or  contains 
much  blood-clot,  pulsation  may  be  absent.  Aneurism  is  mistaken  for 
abscess,  cyst,  or  hygroma  of  the  bursa,  and  soft  solid  tumors.  Careful 
examination  and  regard  for  all  the  individual  signs  make  the  diagnosis 
certain  in  most  cases  if  one  makes  it  a  rule  to  remember  the  possibility 
of  aneurism  in  dealing  with  every  tumor  of  the  popliteal  space. 

Treatment. — By  reason  of  its  situation  the  aneurism  is  fairly  accessible. 
Of  conservative  measures,  systematic  digital  compression  is  of  the 
greatest  value  in  being  simple,  without  discomfort  or  danger,  and  in 
giving  a  large  percentage  of  cures.  The  femoral  artery  is  compressed 
carefully,  but  to  complete  closure,  against  the  horizontal  ramus  of  the 
pubis;  to  be  effectual  the  pressure  should  be  continued  for  one  to  three 
days  at  hourly  intervals.  The  author  cannot  deny  that  this  method, 
generally  regarded  as  harmless,  may  cause  gangrene  of  the  foot,  as 
was  observed  personally  in  one  instance. 


656  DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 

Reid's  method  of  bandaging  the  limb  with  an  Esmarch  to  the  hip, 
leaving  the  aneurism  free,  is  also  approved;  as  its  sudden  release  may 
loosen  recent  clots,  the  bandage  should  be  loosened  gradually  while  the 
artery  is  compressed  digitally  above.  Few  patients  can  endure  the  pain 
of  complete  constriction  of  the  limb  more  than  half  an  hour  without 
anaesthesia;  to  be  successful,  the  constriction  should  be  repeated  on 
alternating  days  for  some  time  or  be  alternated  with  digital  compres- 
sion. 

The  forced  flexion  of  the  knee  and  hip  recommended  by  Adelmann  is 
borne  for  only  a  short  time;  it  is  furthermore  uncertain  and  therefore 
not  especially  advisable.  All  three  methods  are  not  without  considerable 
discomfort  to  the  patient,  but  have  been  effectual,  especially  the  first, 
in  many  instances,  and  therefore  deserve  trial  if  operation  is  refused  or 
counterindicated. 

The  reduction  of  the  danger  of  infection  made  possible  by  asepsis 
has  during  the  last  two  decades  won  over  more  and  more  surgeons  to  the 
operative  treatment  of  aneurism. 

The  methods  to  be  considered  are:  1.  Ligation  of  the  femoral  or 
popliteal  artery.  2.  Preliminary  ligation  of  the  artery  above  and  below 
followed  by  incision  and  evacuation  of  the  sac-contents.  3.  Extirpation. 
[4.  Arteriorrhaphy.] 

Ligation  of  the  Femoral  Artery. — Ligation  of  the  femoral  is 
performed  either  in  Scarpa's  triangle  or  preferably,  but  with  more  diffi- 
culty, as  close  as  possible  to  the  aneurism  beyond  Hunter's  canal.  If 
aseptic,  the  operation  has  few  dangers  aside  from  the  possibility  of 
producing  gangrene  of  the  foot  or  leg,  which,  however,  may  occur 
without  operation.  In  113  cases  of  ligation  of  the  femoral  cited  by 
Delbet  there  was  71  per  cent,  of  recoveries;  other  statistics  are  less 
favorable,  and  no  doubt  also  many  other  unfavorable  cases  have  not 
been  published. 

A  positive  result  is  only  offered  by  the  two  other  operations  [2  and  3], 
both  more  difficult  and  more  dangerous;  total  extirpation  is  unquestion- 
ably the  ideal  method.  It  is  therefore  recommended  by  many  surgeons 
as  the  operation  of  choice  for  all  cases  of  popliteal  aneurism  in  which 
the  bloodless  methods  or  ligation  of  the  femoral  have  failed  if  it  can  be 
performed  without  jeopardizing  the  life  or  the  limb  of  the  patient.  If 
the  sac  cannot  be  removed  without  inflicting  severe  secondary  injuries 
— opening  the  joint,  damaging  the  adherent  popliteal  vein  or  tibial 
nerve — it  is  better  to  incise  and  evacuate,  or  resect  partially  after  ligating 
the  artery  above  and  below.  The  operation  is  performed  under  appli- 
cation of  the  Esmarch,  through  a  long  incision,  the  dissection  being 
carried  carefully  downward  upon  the  vein  and  artery  above  the  tumor; 
if  the  tumor  is  in  the  way,  it  is  opened.  The  articular  branches,  which 
are  often  found  emerging  from  the  sac,  should  be  ligated  to  prevent 
secondary  hemorrhage.  The  cavity  is  drained  or  packed  loosely  with 
gauze. 

Great  care  should  be  used  in  applying  the  dressing  to  prevent 
unequal  pressure. 


POPLITEAL   ANEURISM. 


657 


[Arteriorrhaphy  by  Matas'  Method.— Recently  Rudolph  Matas1 
described  a  new  method  for  the  treatment  of  aneurism  based  upon  the 
fact  that  the  endothelial  surface  of  the  artery  is  "capable  of  exhibiting 
all  of  the  reparative  and  regenerative  reactions  which  characterize  the 

endothelial  surfaces  in  general  when  subjected  to  irritation,"  and  that 
therefore  "the  aneurismal  sac,  with  its  fibrous  basal  membrane  and 
endothelial  intinia  (more  or  less  modified  by  morbid  agencies),  can  be 

Fig.  lor,. 


Interior  of  large  aneurismal  sac  of  the  fusiform  type  exposed  by  retraction.  The  two  openings 
lead  respectively  to  the  parent  trunk  on  the  proximal  (cardiac)  and  peripheral  sides,  and  the  groove 
between  them  represents  the  continuity  of  the  arterial  walls  blending  with  the  aneurismal  sac.  This 
was  the  type  of  sac  observed  in  Cases  1,  2  and  4,  report ed  in  the  text.  The  orifice  of  one  collateral 
or  branch  originating  in  the  sac  is  shown,  and  a  large  collateral  opening  into  the  main  trunk  near 
the  orifice  of  communication,  on  the  cardiac  side,  is  indicated  by  the  dotted  line.     (Matas.) 

properly  regarded  from  the  surgical  viewpoint  as  a  serous  sac  closely 
analogous  to  the  peritoneal  serosa,  and,  as  such,  capable  of  yielding  the 
same  plastic  results  which  have  been  so  helpful  to  the  surgeon  in  his 
interventions  in  the  abdominal  eavitv," 


1  An   Operation  for  the    Radical  Cure  of  Aneurism    Based   upon   Arteriorrhaphy,  Annals  of 
Surgery,  February,  1903. 

Vol.  III.— 42 


658 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


The  method  as  first  conceived  aimed  to  obliterate  the  sac  by  "inverting 
or  infolding  the  walls  of  the  sac  with  the  overlying  skin,"  instead  of 
merely  evacuating  the  contents  and  allowing  the  cavity  to  heal  in  by 
granulation,  as  in  the  ancient  operation  of  Antvllus.  In  the  case  of 
fusiform  aneurisms  the  author  sutures  the  openings  of  all  collaterals 
and  branches  in  the  sac.    Sacciform  aneurisms  he  regards  as  a  proper 

Fig.  406. 


Shows  the  orifices  in  the  aneurismal  sac  in  process  of  obliteration  by  suture.  The  first  plane  of 
sutures  may  be  made  with  fine  silk,  but  chromicized  catgut  is  preferred.  The  sutures  are  applied 
very  much  like  Lembert's  sutures  in  intestinal  work.  The  first  plane  of  sutures  should  be  sufficient 
to  secure  complete  ha?mostasis.  The  orifice  of  the  collateral  vessel  on  the  left  upper  side  of  the  sac 
is  shown  closed  by  three  continuous  sutures.     (Matas.) 


field  for  suture  of  the  opening  of  the  diverticulum,  thus  closing  off  the 
sac  and  -preserving  the  lumen  of  the  artery.  The  author's  4  cases 
operated  on  were  described  in  full  in  the  Transactions  of  the  American 
Surgical  Association  for  1902.  Matas  discussed  the  possibility,  in  the  case 
of  fusiform  aneurisms,  of  restoring  the  normal  lumen  of  the  artery  by 
reefing  the  walls  of  the  aneurism  after  incision  and  evacuation  of  the 
contents,  but  had  not  had  an  opportunity  to  perform  the  operation. 


POPLITEAL  ANEURISM. 


659 


Since  then  it  has  been  done  with  apparent  success  by  Morris1  in  a  case 
of  traumatic  fusiform  popliteal  aneurism,  and  by  Bullock2  in  a  case  of 
traumatic  sacciform  popliteal  aneurism  the  size  of  a  cocoanut. 

The  indications  for  the  operation  given  by  Matas  are  "all  aneurisms 
in  which  there  is  a  distinct  sac,  and  in  which  the  cardiac  end  of  the 
main  artery  can  be  provisionally  controlled.  It  is  especially  applicable 
to  all  forms  of  peripheral  aneurisms  of  the  larger  arterial  trunks  (carotid, 
axillary,  brachial,  iliac,  femoral,  and  popliteal);  and,  while  the  author 


This  shows  a  second  row  of  sutures — a  technical  detail  of  the  operation  which  is  advantageous, 
but  not  necessary  in  every  case.  The  first  row  of  sutures  has  been  completed  and  the  arterial  ori- 
fices have  been  obliterated.  As  the  walls  of  the  sac  are  usually  relaxed,  it  is  easy  to  insert  a  second 
series  of  sutures  which  add  security  to  the  first  row,  and  in  addition  reduce  the  size  of  the  cavity 
which  is  to  be  obliterated  by  inversion  of  the  skin  and  surplus  sac  walls  at  a  later  stage  in  the  opera- 
tion. This  second  row  of  sutures  is  applied  as  in  the  first  series,  by  either  the  continuous  or  inter- 
rupted method,  with  a  curved  needle,  and  Nos.  1,  2,  or  3  chromic  catgut.  A  large  surface  of  the  sac 
is  thus  brought  in  apposition,  and  the  best  opportunity  given  for  adhesion  by  plastic  or  exudative 
endoarteritis.  If  the  floor  of  the  sac  is  rigid  or  too  adherent  to  the  underlying  parts,  this  second  row 
may  be  omitted,  and  the  operation  can  be  advanced  to  the  last  step,  i.  C,  obliteration  of  the  sac 
after  suture  of  the  orifices.     (Matas.) 

has  had  no  experience  with  similar  lesions  of  the  large  visceral  trunks, 
the  principle  suggested  would  appear  to  be  applicable  to  abdominal, 
aortic,  and  other  accessible  forms  of  abdominal  aneurism." 

The  steps  of  the  operation  as  applied  to  peripheral  aneurism  of  the 
larger  arteries  are  as  follows: 


Annals  of  Surgery,  October,  1903. 
American  Medicine,  1903,  vol.  vi.  p.  364. 


660 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


1.  Prophylactic  hsemostasis ;  preliminary  elevation  of  the  limb  and 
control  of  the  circulation  by  means  of  the  Esmarch;  or  a  traction  loop 
around  the  artery  when  the  aneurism  is  high  up  near  the  root  of  a 
limb  (or  in  the  neck);  or  digital  pressure  with  a  sterile  gauze  pad  on 
the  exposed  artery;  or,  better,  by  direct  pressure  with  padded  forceps, 
those  of  Billroth,  Murphy,  Burci,  or  a  special  clamp,  Crile's,  Allegiani's, 
J.  Tilden  Brown's,  v.  Langenbeck's,  Serre-Plat's  (Tomaselli),  etc.  Matas 

Fig.  40S. 


Shows  the  details  of  the  method  of  obliteration  after  the  floor  of  the  sac  has  been  raised  by  the 
second  row  of  sutures.  Two  deep  supporting  and  obliterating  sutures  of  chromic  catgut  are  inserted 
through  the  floor  of  the  sac  on  each  side.  The  number  of  these  sutures  will  vary  according  to  the 
size  and  length  of  the  sac  that  is  being  treated.  In  the  smaller  aneurisms,  one  of  the  deep  sutures 
on  each  side  will  suffice;  in  others  two  or  more  on  each  side  may  be  required  to  keep  the  surfaces  in 
close  contact.  After  the  sutures  are  passed  through  the  floor  of  the  sac  the  free  ends  of  the  threads 
are  carried  through  the  entire  thickness  of  the  flap  by  transfixion.  The  plate  shows  the  mode  of 
placing  these  sutures  on  the  left  side  preparatory  to  transfixion  of  the  flap.  The  two  sutures  on  the 
right  side  have  been  carried  through  a  flap  and  are  in  position.    (Matas.) 


finds  a  simple  silk  traction  loop  the  most  convenient,  but  regards  a 
properly  fitting  adjustable  clamp  as  preferable  (Crile's  or  Allegiani's 
compressor). 

2.  Incision  of  the  skin  and  exposure  of  the  sac.  A  long  incision  is 
made  parallel  with  the  axis  of  the  aneurism,  the  sac  exposed  from  one 
end  to  the  other  (by  careful  dissection  in  the  case  of  deep-seated  tumors 


roi'UTlCAL  am:  11! ISM. 


661 


to  avoid  the  adjacent  nerves,  arteries,  and  veins),  and  all  nerves  or 
other  structures  found  adherent  to  the  sac  freed  carefully  and  re- 
tracted. 


tl 


3.  Opening  of  the  sac  and  evacuation  of  its  contents,  recognition  of 
ie  type  of  the  sac,  number  of  openings,  etc.  The  sac  is  incised  from 
one  pole  to  the  other  in  the  axis  of  the  artery,  the  blood-clots  evacuated, 
and  the  cavity  freely  exposed  by  retracting  the  edges  to  determine  its 
nature,  whether  fusiform  or  sacciform.  If  fusiform,  two  large  open- 
ings will  be  found,  usually  at  the  bottom  of  the  sac,  separated  by  an 
intervening  space  of  variable  length,  frequently  grooved  and  represent- 


Fig.  409. 


Shows  the  deep  supporting  sutures  in  position  and  the  details  of  transfixion  of  the  flaps.  The 
Reverdin  needle  is  used  to  carry  the  free  ends  of  the  threads  through  the  flaps  formed  by  the  skin 
and  aneurismal  walls.     Olatas.) 


ing  the  floor  of  the  artery.  This  is  more  common  in  aneurisms  of  the 
extremities  than  elsewhere.  If  sacciform,  there  is  a  single  ovoidal  or 
circular  opening  of  varying  size  communicating  with  the  artery. 

The  importance  of  thus  distinguishing  two  fundamental  varieties 
with  reference  to  the  subsequent  technic,  as  emphasized  by  Matas,  may 
be  modified  in  time  if  Morris'  success  in  reefing  the  wralls  in  his  case  of 
traumatic  fusiform  popliteal  aneurism  is  borne  out  by  experience  in 
similar  cases;  in  other  words,  the  operation  for  restoring  the  lumen  of 
the  artery  will  differ  in  the  case  of  fusiform  and  sacciform  aneurisms, 
not  so  much  in  kind  as  in  extent.     As  stated,  Matas  recognized  this 


662 


DISEASES  IN  A XI)  ABOUT  THE  KNEE-JOINT. 


possibility  and  gave  the  technic  for  such  cases  of  fusiform  aneurisms, 
analogous  to  Witzel's  method  of  gastrostomy.     (Tigs.  415,  416,  and  417.) 


Fig.  410. 


Fig.  411. 


T 


I      siU-s.'  \  y^ 


Fig.  410. — Show?  the  operation  completed.  In  this  figure  only  two  supporting  suture*  are  shown 
on  each  side  instead  of  the  four  shown  in  the  other  figures.  The  skin  and  sac  wall>  form  two  lateral 
flaps  on  each  side  of  the  incision,  and  readily  fall  to  the  bottom  of  the  sac.  thus  lining  and  obliterat- 
ing the  entire  cavity.  A  series  of  interrupted  absorbable  sutures  are  now  placed  so  as  to  bring  the 
edges  of  the  skin  in  contact,  several  of  these  including  the  floor  of  the  sac  in  their  bight.  - 
close  the  space  entirely  in  the  middle  line.  The  two  lateral  supporting  sutures  are  tied  firmly  over 
small  pads  or  rolls  of  sterile  gauze,  thus  bringing  all  the  interior  of  the  sac  in  apposition.     (Matas.) 

Fio.  411 . — This  shows  a  typical  sacciform  aneurism  with  one  main  orifice  of  communication  open- 
ing into  the  sac.     In  this  type  of  aneurism  the  lumen  of  the  parent  artery  is  maintained.     II 
sible  in  this  class  of  cases  to  close  the  orifice  of  communication  by  suture  without  obliterating  the 
lumen  of  the  artery,  and  without  interfering  with  the  circulation  in  the  main  artery  of  the  distal 
parts  supplied  by  it.     CMatas.) 


4.  Closure  of  the  aneurismal  orifices  in  the  fusiform  type  of  sac.  In 
the  case  of  fusiform  aneurisms  in  which  the  continuity  of  the  arterial  wall 
cannot  be  restored,  Matas  recommends  suture  of  the  openings  leading 
into  the  sac  and  obliteration  of  the  cavity   (Figs.  405,  406,  and  418), 


POPLITEAL   A.\/:rilISM. 


663 


after  removing  the  clots  and  swabbing  out  the  cavity  with  salt  solution. 
As  suture  material  he  prefers  absorbable  sutures — chromicized  catgut, 
Nos.  1,  2,  •'! — although  twisted,  braided  or  floss  silk,  or  fine  kangaroo- 
tendon  may  be  used;  and  of  needles  (Mayo,  Kelly,  Ferguson,  Hagedorn ) 

those  which  are  round,  full  curved,  with  long  eyes  and  prismatic  points. 
It  is   important  to  bring  broad  surfaces  of  the  sac  into  apposition,  so  the 

Fig.  412. 


This  figure  is  simply  intended  to  show  the  same  type  of  sacciform  aneurism  viewed  from  the 
posterior  side.  The  parent  artery  is  continuous  throughout,  and  is  simply  attached  to  the  sac  at  the 
orifice  of  communication.  The  artery  has  been  laid  open  on  its  posterior  surface,  showing  that  the 
orifice  of  communication  can  be  closed  on  the  aneurismal  side,  without  occluding  the  lumen  of  the 
parent  artery.  The  drawing  is  taken  from  a  pathological  specimen  and  is  utilized  solely  to  show  the 
favorable  anatomical  characteristics  of  this  class  of  aneurism  for  the  conservative  procedure  sug- 
gested by  the  author.     (Matas.) 


needle  should  penetrate  at  least  \  or  £  of  an  inch  beyond  the  margin  of 
the  orifice,  and  then,  after  reappearing  at  the  margin,  dip  again  into 
the  floor  of  the  artery  and  continue  to  the  opposite  margin  as  in  the 
start.  (Fig.  406.)  Where  it  is  necessary  to  close  the  openings  quickly,  the 
margins  mav  be  brought  together  rapidly  with  a  continued  suture.  In 
obliterating  the  sac  Matas  has  found  it  an  advantage  to  suture  the  floor 
between  the  two  orifices  (Fig.  406),  on  the  Lembert  plan.     This  raises 


664 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


the  floor  and  decreases  the  transverse  diameter;  it  cannot  be  done  if 
the  tissues  are  rigid.     The  subsequent  steps  are  considered  later. 

5.  In  sacciform  aneurisms  with  a  single  orifice  of  communication 
haemostatic  and  reconstructive  suture  is  employed  with  the  view  of  pre- 
serving the  lumen  of  the  parent  artery.  (Figs.  411  and  412.)  Like  ma- 
terial and  needles  are  used  as  in  fusiform  aneurisms,  the  essential  being 

Fig.  413. 


Shows  the  same  sac  opened.  The  dotted  lines  indicate  the  position  and  relations  of  the  main 
artery  to  the  sac  and  to  the  orifice  of  communication.  The  object  of  the  operation  in  this  case  is  to 
close  the  orifice  of  communication  without  obliterating  the  main  artery.  The  closure  of  the  orifice 
with  continued  suture  is  shown  in  the  plate.     (M;itas.) 


to  insert  the  suture  at  a  sufficient  distance  from  the  usually  thick  and 
smooth  margins  of  the  opening  to  secure  a  firm  and  deep  hold  of  the 
fibrous  basal  membrane,  and  to  make  the  resulting  lumen  equal  in  size 
to  that  of  the  artery.  The  threads  should  not  be  in  contact  with  the 
blood  in  the  lumen  of  the  artery. 

As  shown  in  Figs.  413  and  414,  it  will  be  advantageous  to  begin 
the  line  of  suture  at  some  distance  from  the  orifice,  as  this  will  secure 
a  broader  and  stronger  line  of  approximation. 


I'OPLITEA  L  .  1  M-:  I  A'  ISM. 


665 


(i.  Removal  of  the  constrictor  and  (est  of  sutures.  After  closing  all 
visible  openings,  on  removing  the  compression  the  cavity  should  be 
perfectly  dry.  Oozing  points  are  usually  stopped  by  pressure  or  the 
subsequent  steps. 

7.  Obliteration  of  the  aneurismal  sac.  (Figs.  407,  408, 409,  and  410.) 
This  step  of  the  operation  is  the  same  in  all  eases.     If  the  cavity  is  large, 

Fig.  414. 


This  shows  the  closure  of  the  orifice  of  communication  in  the  same  type  of  sac  with  interrupted 
instead  of  continued  suture.  Whether  the  continued  or  the  interrupted  suture  be  used  (the  former 
being  preferred  by  the  author)  it  is  important  to  begin  the  suture  line  at  some  distance  from  the 
orifice,  so  as  to  infold  a  considerable  surface  of  the  sac  at  the  start;  then  care  must  be  exercised  to 
insert  the  sutures  so  as  to  grasp  a  considerable  surface  of  the  margin,  in  a  manner  that  the  point  of 
the  needle  shall  penetrate  the  entire  thickness  of  the  margin,  and  yet  not  so  far  within  the  lumen  of 
the  artery  as  to  encroach  upon  the  calibre  or  to  leave  the  suture  material  in  contact  with  the  blood 
current.  When  the  sutures  are  tightened  they  should  bring  the  marginal  surfaces  in  broad  appo- 
sition without  projecting  into  the  anterior  portion  of  the  artery  or  encroaching  excessively  upon  the 
lumen  of  the  vessel.     (Matas.) 


it  is  well  to  reinforce  the  first  row  of  sutures  by  a  second  row,  applied  on 
the  Lembert  plan  on  a  higher  level.  The  remaining  space  is  then  closed 
by  turning  in  the  skin-flaps,  which  are  held  down  by  one  or  two  relaxation 
sutures  applied  on  each  side  of  the  median  line  with  a  large-sized  full- 
curved  intestinal  needle,  grasping  a  considerable  portion  of  the  sac  in  its 


666 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


Fig.  415. 


Fig.  416. 


Sectional  diagram  showing 
method  of  obliterating  the 
aneurisma!  sac  in  the  fusiform 
type  of  aneurism  with  two  open- 
ings. In  this  class  of  cases  (Figs. 
405  and  406)  the  tunics  of  the 
parent  artery  blend  with  the  sac, 
and  the  arterial  cavity  cannot 
usually  be  restored.  The  dia- 
gram shows  the  first  row  of 
sutures  (I)  which  obliterates 
the  orifice  of  the  artery  at  the 
bottom  of  the  sac.  The  second 
row  of  sutures  is  shown  higher 
up  (II)  and  also  the  effect  of  this- 
row  in  reducing  the  capacity  of 
the  sac.  The  obliteration  of  the 
remaining  part  of  the  cavity  by 
the  folding  in  or  inversion  of  the 
sac  walls,  with  the  attached  over- 
lying skin,  is  shown  in  III.  The 
function  of  the  deep  sutures  (IV) 
tied  over  gauze  pads,  and  of  the 
more  superficial  skin  sutures  (V), 
in  obtaining  firm  contact  of  the 
opposed  surfaces,  is  also  shown. 
Thisdrawing  ispurelyschematic; 
it  gives  an  exaggerated  idea  of 
the  size  of  the  sac  walls,  and  is 
chiefly  intended  to  give  an  idea 
of  the  position  of  the  sutures 
and  other  parts.     (Matas.) 


Shows  a  possible  but  not  yet 
tried  method  of  restoring  the 
large  lumen  of  the  parent  artery 
in  favorable  cases  of  fusiform 
aneurism  with  two  opening-  in 
which  the  healthy  and  flexible 
character  of  the  sac  will  permit 
of  the  restoration  of  the  arterial 
channel  by  lifting  two  lateral 
folds  of  the  sac  and  bringing 
them  together  by  suture  over 
a  soft  rubber  guide.  The  prin- 
ciple of  this  operation  is  pre- 
cisely like  that  adopted  in  a 
Witzel  gastrostomy.  The  figure 
shows  the  soft-rubber  catheter 
lying  on  the  floor  of  the  sac  and 
inserted  in  the  two  orifices  of 
communication.  The  sutures 
are  placed  while  the  catheter 
is  in  position  acting  as  a  guide. 
(Matas.) 


PLATE  XVII 


Aneurism  of  the  Popliteal  Artery.     (Jacob.) 


POP  LITE  A  L  A  A7-;  /  7/  ISM. 


667 


bight.  The  needle  should  penetrate  the  entire  thickness  of  the  sac;  by 
carrying  it  through  in  this  way  a  loop  is  formed,  the  ends  of  which  are 
carried  through  the  skin-Haps  by  transfixation  with  a  straight  Reverdin 
needle,  and  tied  firmly  over  a  loose  pad  of  gauze  after  the  flaps  have 
been  carefully  adjusted  in  position.  (Figs.  40N,  409,  and  410.)  A  few 
interrupted    catgut    skin    sutures    complete    the  operation.     (Fig.  410.) 

'  Fig.  417. 


This  shows  a  more  advanced  step  of  the  procedure  described  in  Fig.  416.  The  sutures  are  nearly 
all  tied,  and  the  new  channel  is  completed  except  in  the  centre.  The  two  middle  sutures  are  hooked 
and  pulled  out  of  the  way  while  still  in  position,  and  the  catheter  is  withdrawn.  The  obliteration  of 
the  sac  and  final  steps  of  the  operation  are  carried  out  precisely  as  described  in  Figs.  407,  40S,  409, 
and  410.      (.Matasj 

As  no  exposed  or  raw  surfaces  are  left  in  view,  there  is  no  need  for 
drainage,  and  union  per  primam  can  be  confidently  expected. 

A  simple  sterile  gauze  dressing  is  applied  as  a  graduated  compress  to 
fill  the  hollow  left  in  the  place  previously  occupied  by  the  aneurism,  and 
held  in  position  by  a  few  strips  of  aseptic  rubber  plaster.  A  thick 
layer  of  cotton-batting  envelops  the  limb  from  periphery  to  trunk. 
Immobilization  is  secured  by  means  of  a  well-padded  splint,  or  starch, 
or  plaster-of-Paris  roll  bandage.     If  there  are  no  reasons  to  the  con- 


668 


DISEASES  IN  AND  ABOUT  THE  KNEE-JOINT. 


trary,  the  first  dressing  should  not  be  disturbed  for  a  period  of  a  week  or 
ten  days. 

It  is  to  be  regretted  that  the  original  article  of  Matas  from  which  the 
above  description   has  been   freely   derived   cannot  be  given  more  in 

Fig.  418. 

LeftErachial. 


Ligature. 


v/vm. 


Inf  P/r, 


'aru\^~ 


/Jlnar 


RaZ]//>L 


This  is  a  reproduction  of  a  diagram  published  in  the  Medical  News  (Philadelphia).  October  27, 
1SS8.  It  is  intended  to  explain  the  condition  found  in  a  case  of  traumatic  aneurism  in  which  Dr. 
Matas  applied  intravascular  arteriorrhaphy  for  the  first  time.  The  abundance  of  the  collateral 
supply  in  that  case  could  only  be  accounted  for  by  a  distribution  of  the  vessels  such  as  shown  in 
this  figure.  The  failure  of  the  ligatures  applied  to  the  main  artery  above  and  below  the  sac  and  dif- 
ficulties of  extirpation  were  well  illustrated  in  this  case,  and  led  to  the  suture  of  the  aneurismal 
orifices,  which  promptly  secured  their  obliteration  and  an  immediate  arrest  of  the  hemorrhage. 
(Matas.) 


detail.  The  reader  is  therefore  urgently  recommended  to  consult  the 
same,  which  is  regarded  as  "one  of  the  most  important  of  the  recent 
contributions  to  surgery."] 


MALFORMATIONS,  INJURIES,  AND  DISEASES  OF 

THE  LEG. 


CHAPTER   XXXII. 

MALFORMATIONS  OF  THE  LEO. 

Total  defect  of  the  foot  or  leg  is  of  slight  practical  interest  to  the  sur- 
geon. The  stump,  often  small,  consists  of  skin  and  fat,  and  occasionally 
has  appendages  covered  by  a  nail  which  remind  one  of  rudimentary 
toes.  The  anomalies  are  due  partly  to  faulty  construction,  partly  to 
constriction  by  amniotic  bands.  In  the  latter  case  there  are  sometimes 
one  or  more  deep  circular  constrictions  on  the  leg  which  may  extend 
down  to  the  bone.  The  parts  below  the  constriction,  if  it  is  slight,  may 
be  almost  normal;  in  other  instances  they  are  atrophic  and  show  anom- 
alies in  development  and  position.  Defects  of  single  bones  of  the  leg 
are  more  important;  they  may  be  partial  or  complete.  Defect  of  the 
fibula  is  more  frequent  than  that  of  the  tibia :  if  partial  of  the  fibula,  it  is 
usually  the  upper  portion  that  is  lacking;  of  the  tibia,  the  lower  portion. 
With  defect  of  the  fibula  are  usually  associated  an  absence  of  one  or 
more  toes  and  a  characteristic  anomalous  position  of  the  foot  in  ever- 
sion  as  in  flat-foot ;  the  foot  may  even  lie  against  the  outer  side  of  the 
leg.  The  tibia  may  be  normal;  but  the  talocrural  joint  is  more  or  less 
subluxated.  In  other  instances  the  tibia  is  curved,  most  frequently  in 
the  lower  third  with  the  convexity  inward.  (Fig.  419.)  This  curvature 
is  referred  by  many  to  intra-uterine  fracture. 

With  defect  of  the  tibia  the  knee-joint,  which  is  usually  intact  in  con- 
nection with  defect  of  the  fibula,  is  more  or  less  changed  as  a  rule,  and 
always  changed  with  total  defect.  The  fibula  is  dislocated  backward 
and  articulates  loosely  with  the  outer  condyle  of  the  femur.  The  leg  is 
flexed,  adducted,  atrophic,  and  the  entire  limb  undeveloped.  The 
fibula  is  always  curved,  usually  convex  forward;  the  foot  is  strongly 
adducted.  As  the  deformities  increase  the  longer  the  limb  is  disused, 
it  is  important  to  correct  the  same  as  soon  and  as  far  as  possible  and  to 
make  the  limb  useful  by  means  of  a  supporting  apparatus.  According 
to  the  degree  of  curvature  and  the  age  of  the  patient  manual  correction, 
osteotomy,  resection  of  the  joint,  or  arthrodesis  of  the  knee  or  ankle,  or 
of  both,  are  to  be  considered.  Recently  the  joint  has  been  stiffened 
successfully,  in  the  case  of  the  ankle,  by  Bardenheuer  with  the  modifica- 
tion of  splitting  the  tibia  and  inserting  the  astragalus  in  the  fork  thus 
formed.  In  view  of  the  shortening  of  the  limb  it  is  often  advisable  to  anky- 
lose  the  foot  in  a  pes  equinus  position  and  not  at  a  right  angle  to  the  leg. 

(  669) 


670 


MALFORMATIONS  OF  THE  LEG, 


The  so-called  intrauterine  fractures  of  the  leg  (Fig.  420)  belong 
here  more  properly,  as  it  is  still  uncertain  whether  they  are  always 
fractures.  Fractures  of  the  bones  of  the  extremities  in  utero  from 
external  violence,  although  rare,  are  unquestionable;  they  usually 
heal  by  callus  with  displacement,  but  may  give  rise  to  a  pseudarthrosis. 
The  same  name  has  been  applied  to  congenital  curvatures  of  the  bones 
of  the  leg  in  which  the  most  careful  histological  examination  has 
shown  no  trace  of  previous  separation  of  continuity  or  callus.  These 
curvatures,  which,  as  stated,  are  frequent  in  the  tibia  in  connection 
with  defects  of  the  fibula,  also  occur  simultaneously  in  both  bones  of  the 


Fig.  419. 


Fig.  420. 


Defect  of  the  fibula  and  one  toe  in  addition  to  a  so- 
called  intrauterine  fracture  of  the  tibia.   (Reichel.) 


Intrauterine  fracture  of  the  leg  in  a 
child  four  years  old. 


leg;  as  a  rule  they  are  located  at  or  below  the  junction  of  the  lower 
and  middle  third;  the  convexity  is  directed  forward.  The  skin  at  the 
summit  of  the  curve  of  the  tibia  often  shows  a  small  white  cicatricial 
spot,  slightly  depressed,  to  which  a  piece  of  amnion  is  attached;  this 
would  seem  to  indicate  that  the  curvature  was  caused  by  the  pressure  of 
an  unduly  small  amniotic  sac  or  that  it  is  due  to  amniotic  adhesions  and 
bands  acting  at  an  earlier  period.  The  curved  bones  are  thinner  than 
in  the  other  normal  limb  and  like  the  overlying  soft  parts  remain  some- 
what atrophic  in  the  further  development.  The  flexed  position  of  the 
foot  gradually  increases  as  the  limb  is  used. 

The  prognosis  is  unfavorable  as  there  is  little  tendency  to  formation 
of  bone  at  the  point  of  curvature  with  or  without  operation,  hence  there 
is  often  insufficient  callus  formation  and  pseudarthrosis.     (Fig.  420.) 


CHAPTER  XXXIII. 

INJURIES  OF  THE  LEG. 
FRACTURE  OF  THE  SHAFT  OF  THE  BONES  OF  THE  LEG. 

Next  to  fractures  of  the  forearm,  those  of  the  leg  are  most  common, 
according  to  v.  Bruns  16  per  cent,  of  all  fractures.  They  occur  at  any 
age,  even  in  utero  and  intrapartum,  but  are  far  more  frequent  in  well- 
developed  adults,  and  in  men  than  in  women.  This  is  easily  explained  by 
the  conditions  always  connected  with  hard  labor.  Direct  fractures  are 
more  frequent  than  the  indirect,  the  common  causes  being  blows  from 
heavy  falling  bodies,  run-over  accidents,  hoof-blows,  etc.  Indirect  frac- 
ture is  caused  by  falling  upon  the  feet  from  a  height  (compression)  or  by 
accidents  with  the  foot  held  fast  (inflexion  or  torsion  or  both).  Also  in 
the  cases  due  to  direct  violence  the  fracture  is  exceptionally  produced  by 
compression,  but  usually  by  bending,  in  the  same  way  that  a  stick,  held 
at  both  ends,  is  broken  by  a  blow  against  the  middle.  On  account  of 
the  thickness  of  the  head  of  the  tibia  and  the  prominence  of  the  malleoli 
and  heel,  it  rarely  happens  that  the  shaft  is  supported  in  its  entire 
length,  even  in  the  case  of  run-over  accidents.  In  not  a  few  of  the  indi- 
rect fractures  there  is  a  combined  torsion  and  bending  action,  as  in  fall- 
ing from  the  effects  of  a  blow  with  the  foot  fixed.  Inflexion  fractures 
are  rare.1 

As  it  is  the  tibia  that  actually  supports  the  body,  it  is  clear  that  at  the 
moment  of  fracture  the  fibula  cannot  alone  withstand  the  weight  of 
the  body  and  so  breaks,  hence  the  frequency  of  fracture  of  both  bones. 
The  site  of  fracture  is  usually  at  the  junction  of  the  lower  and  middle 
third.  Direct  fractures  occur  at  any  point  according  to  the  place  at 
which  the  violence  is  applied.  In  the  upper,  stronger  third,  however, 
they  can  only  result  from  very  great  violence.  The  fibula  usually 
breaks  a  trifle  higher  than  the  tibia.  Double  fractures  are  not  common; 
in  fracture  by  bending  a  wedge  is  often  broken  off,  its  base  correspond- 
ing to  the  concavity  of  the  curve. 

The  line  of  fracture,  in  spite  of  the  great  frequency  of  direct  violence, 
is  transverse  in  only  a  small  number  of  cases,  as  the  surgeon  is  usually 
dealing  with  a  fracture  by  bending;  the  surfaces  are  serrated,  the  inter- 
locking of  the  teeth  preventing  any  great  displacement.  (Fig-  421.) 
Commonly  the  line  is  oblique,  generally  from  above  and  behind,  down- 

1  From  the  above  it  will  be  seen  that  the  author  distinguishes  of  the  fractures  due  to  violence 
applied  against  the  shaft :  those  in  which  the  ends  of  the  shaft  are  fixed  while  the  force  is  applied 
somewhere  between  the  two  ends  (fracture  by  bowing),  and  those  in  which  one  end  and  part  of 
the  shaft  are  fixed  while  the  force  "snaps  off"  the  bone  somewhere  beyond  these  points  of  sup- 
port (fracture  by  inflexion). 

(671) 


672 


INJURIES  OF  THE  LEG. 


ward  and  forward,  although  not  infrequently  in  the  reverse  direction. 
This  characteristic,  so-called  "flute  mouth-piece  form"  (Flotenschnabel- 
form)  of  the  fragments  is  liable  to  cause  impalement  or  perforation  of 
the  soft  parts.  (Fig.  422. )  The  wedge-shaped  fragment  of  the  frac- 
ture by  bowing  is  not  infrequently  broken  into  several  pieces.  Spiral 
fracture  by  torsion  (fract.  en  V,  Gosselin;  fraet.  en  coin  or  cuneenne, 


Fig   421. 


Fig.  422. 


Serrated  transverse  fracture  of  the  shaft  of 
tibia  and  fibula  in  a  boy.     (v.  Bruns.) 


Very  oblique  ("clarinet  mouth-pipce"  I  fracture  of 
tibia  and  double  fracture  of  fibula,  (v.  Bruns.) 


Larrey)  is  rather  common,  according  to  v.  Bruns  more  frequent  in  the 
lower  half  of  the  tibia  than  in  any  other  bone.  A  fissure  not  infre- 
quently runs  from  the  re-entrant  hollow  angle  of  one  or  both  fragments 
into  the  adjacent  joint,  sometimes  in  the  continuation  of  the  spiral, 
sometimes  in  a  line  joining  its  ends.  (Figs.  423  and  424.  |  The  severity 
of  the  direct  violence  explains  the  frequency  of  comminution,  of  multiple 
fractures,  and  of  splintering  of  the  entire  shaft.     (Fig.  425.)     Lauen- 


FRACTURE  OF  THE  SHAFT  OF  THE  BONES  OF  THE  LEG.     673 


stein  calls  attention  to  an  apparently  typical  injury,  avulsion  of  a  plate 
of  hone-  from  the  anterior  surface  of  the  lower  end  of  the  tibia;  the  base  of 
the  fragment  is  below,  and  is  held  by  the  anterior  pari  of  the  capsule 
of  the  ankle-joint ;  above,  this  fragment  tapers  to  a  point  or  ends  more 
bluntly.  In  the  I  cases  seen  by  him  the  fracture  was  due  to  a  fall  from 
a  height,  and  was  always  complicated  by  other  injuries  of  the  leg. 


Fig.  423. 


Fig.  424. 


Fig.  42.i. 


Fig.  423. — Spiral  fracture  of  the  leg.     (v.  Brans.) 

Fig.  424. —  Spiral  fracture  of  the  tibia  with  fissure  into  the  ankle-joint,  posterior  view.  (v.  Brans.) 

Fig.  42.5  — Extensive  comminution  of  both  bones  of  the  leg  due  to  run-over  accident,  (v. Brans.) 

A  considerable  number  of  the  fractures  are  compound;  in  indirect 
fractures  usually  from  perforation  of  the  soft  parts  by  a  sharp  frag- 
ment, but  with  very  little  laceration  of  the  tissues;  the  soft  parts  may 
become  interposed  between  the  fragments  and  necessitate  incision  to 
effect  reduction.  Or  a  subcutaneous  fracture  may  become  compound 
secondarily  by  pressure-necrosis  of  the  skin.  In  direct  compound 
Vol.  III.— 43 


<37-±  INJURIES  OF  THE  LEG. 

fractures  the  skin  is  generally  broken  by  the  trauma  and  the  deeper 
tissues  more  or  less  contused  and  necrosed.  The  size  of  the  skin-wound 
does  not  denote  the  amount  of  damage  to  the  muscles  or  bone;  the 
wound  may  be  large  and  the  bone  only  fractured  obliquely  or  trans- 
versely at  one  spot,  or  it  may  be  small  and  yet  the  bone  be  splintered 
severely  and  the  muscles  torn  or  crushed.  In  severe  cases  in  which  the 
wound  extends  down  to  the  fracture  the  large  vessels  and  nerves  may  be 
contused.  In  contrast  to  a  simple  fracture  which  has  perforated  the 
skin  and  which  may  be  regarded  as  aseptic  if  recent,  compound  fractures 
due  to  direct  violence  are  often  soiled  by  dirt,  pieces  of  clothing,  etc., 
and  so  must  be  regarded  and  treated  as  infected. 

In  gunshot  fractures,  especially  those  made  by  the  modern  small- 
calibre  weapons,  although  the  wound  of  the  soft  parts  is  slight,  the 
tibia  is  very  apt  to  be  severely  splintered;  fissures  usually  extend  into 
one  or  both  adjacent  joints.  Round-hole  penetrating  gunshot  wounds 
are  seen  almost  exclusively  in  the  spongiosa  of  the  head  of  the  tibia. 

Displacement  of  the  fragments  may  be  absent  in  transverse  fractures, 
but  is  common  in  oblique  fractures;  the  nature  of  the  displacement 
depending  largely  on  the  line  of  fracture.  Usually  the  lower  fragment 
is  displaced  outward,  backward,  and  upward;  occasionally  forward 
and  inward.  With  this  lateral  displacement  are  usually  combined 
shortening,  axial  inflexion  at  an  obtuse  angle  opening  backward,  and 
outward  rotation  of  the  foot.  In  double  fractures  the  nature  of  the  dis- 
placement may  vary  greatly.  If  the  fragments  are  much  separated,  the 
muscles  easily  become  interposed  and  impaled. 

Diagnosis. — The  deformity  due  to  displacement  and  shortening  in 
the  majority  of  cases  gives  the  diagnosis  at  a  glance;  if  not  pronounced, 
it  is  increased  by  the  effort  to  lift  the  leg.  The  superficial  situation  of 
the  anterior  border  and  surface  of  the  tibia  permits  of  accurate  palpa- 
tion and  the  detection  of  even  slight  irregularities  along  the  bone,  espe- 
cially in  recent  injuries.  In  a  few  hours,  or  even  sooner,  palpation  is 
hindered  by  the  pain  and  swelling;  by  carefully  pitting  the  swelling 
with  the  fingers  the  contour  of  the  tibia  can  almost  always  be  felt.  The 
examination  for  fracture  therefore  should  always  begin  with  this  harm- 
less and  least  painful  manipulation.  If  this  is  not  conclusive,  false 
motion  and  crepitus  may  be  elicited  by  seizing  the  leg  above  and  below 
the  point  of  tenderness  and  shifting  the  fragments;  usually  both  these 
symptoms  are  very  distinct  except  with  impaction;  crepitus  may  be 
prevented  by  interposition  of  the  soft  parts,  but  false  motion  is  then 
pronounced,  and  bony  crepitus  can  be  felt  on  overcoming  the  inter- 
position. The  line  of  fracture  may  be  determined  by  simple  palpation 
alone  or  by  shifting  the  fragments  upon  each  other.  If  the  latter  is 
necessary,  it  is  always  better  to  decide  first  whether  anaesthesia  is  required 
for  reduction,  and  to  avoid  further  painful  manipulation  until  treatment 
is  instituted.  In  the  absence  of  any  displacement  anaesthesia  is  unneces- 
sary; the  characteristic  localized  point  of  tenderness  then  becomes  very 
significant,  and  a  fracture  may  be  assumed  and  the  treatment  made  to 
correspond. 


FRACTURE  OF  THE  SHAFT  OF  THE  BONES  OF  THE  LEG.     675 

Prognosis. — Simple  fractures  heal  by  bony  union  in  children  in  about 
three  or  four  weeks;  in  adults  in  six  to  eight  weeks.  Consolidation  is 
proportional  to  the  accuracy  of  coaptation  and  immobilization.  Any 
great  displacement  persisting  may  mean  consolidation  delayed  for 
many  weeks  or  even  pseudarthrosis.  Delayed  union  is  sometimes  seen 
without  apparent  local  or  constitutional  cause;  but  these  cases  are 
rare. 

Bony  union  between  the  tibia  and  fibula  is  occasionally  observed, 
generally  as  the  result  of  unreduced  displacement. 

Union  without  some  displacement,  except  where  there  is  no  tendency 
to  such,  is  rare,  as  shown  more  recently  by  the  x-ray.  Slight  lateral 
displacement  and  overlapping  of  the  lower  fragment,  corresponding  to 
the  obliquity  of  the  surfaces,  some  axial  deviation  with  prominence 
of  the  tip  of  the  upper  fragment,  or  inversely  backward  curvature  of 
the  leg  with  the  concavity  forward,  are  of  rather  frequent  occurrence; 
the  same  applies  to  the  persistence  of  a  certain  amount  of  inward  or 
outward  rotation  of  the  lower  fragment.  Even  greater  displacement 
and  shortening  can  usually  be  prevented  and  overcome  if  properly 
treated.  The  functional  disturbance,  as  a  rule  proportional  to  the 
amount  of  displacement,  is  fortunately  less  in  fractures  of  the  leg 
than  one  would  suppose  from  the  x-ray  pictures.  With  firm  union, 
a  movable  joint,  and  not  too  much  displacement,  the  limb  becomes 
strong  with  use,  although  the  patient  may  complain  for  years — 
especially  as  long  as  an  indemnity  can  be  claimed — of  indefinite  pains 
in  the  limb,  particularly  with  weather-changes.  Even  in  the  case  of 
uneventful  recovery  without  displacement  a  certain  amount  of  stiff- 
ness persists  in  the  ankle-  and  knee-joint  from  immobilization,  so 
that  the  full  working-ability  is  rarely  recovered  before  three  months, 
often  not  before  six  months  or  a  year  or  longer.  The  stiffness  is  less 
than  that  following  fractures  of  the  ankle,  except  in  the  case  of  fissures 
extending  to  the  joint  and  producing  ha?marthrosis,  or  in  older  individ- 
uals with  arteriosclerosis,  cardiac  weakness,  oedema  due  to  circulatory 
disturbances,  or  a  tendency  to  arthritic  processes. 

Compound  fractures  with  small  skin-wounds,  especially  those  due  to 
outward  perforation,  if  kept  aseptic,  often  heal  in  the  same  manner  and 
time  as  simple  fractures.  Generally  more  time  should  be  allowed  for 
recovery,  however,  in  spite  of  the  fact  that  union  is  frequently  better  than 
in  simple  fractures  with  persisting  displacement.  The  prevention  of  infec- 
tion and  phlegmon,  the  first  essential  of  treatment,  often  requires  a  dress- 
ing too  large  to  insure  the  exact  immobilization  obtainable  in  simple 
fractures.  Further,  the  frequently  severe  damage  of  the  deeper  soft  parts, 
especially  the  muscles,  is  always  accompanied  by  a  certain  amount  of 
adhesion  and  cicatricial  tissue  formation  which  hinders  restoration  of  the 
normal  function,  the  more  so  as  the  wound  prevents  early  massage.  All 
these  conditions  are  made  more  unfavorable  by  any  necessary  extensive 
incisions  or  packing,  and  especially  by  suppuration,  phlegmon,  or  necrosis 
of  splinters  or  of  the  fracture-ends.  Although  antisepsis  has  fortunately 
made  it  possible  as  a  rule  to  save  the  life  and  limb  of  the  patient,  still 


676 


INJURIES  OF  THE  LEG. 


Fig.  426. 


at  times,  in  spite  of  careful  treatment,  the  surgeon  is  compelled  to  resort 
to  secondary  incisions,  resection,  or  amputation. 

The  prognosis  of  compound  fractures,  even  with  small  skin-wounds, 
is  always  more  serious  than  that  of  simple  fractures,  and  the  functional 
result  is  generally  less  satisfactory.  The  author  cannot  subscribe  unre- 
servedly to  the  statement  in  a  well-known  text-book  that  "  the  compound 
fractures  of  the  leg  formerly  so  dreaded  on  account  of  suppuration, 
necrosis,  and  pyaemia  recover  uneventfully  under  antiseptic  precautions." 
The  unfavorable  prognosis  which  obtains  in  reference  to  intrapartum 
fractures  of  the  leg  is  based  upon  the  fact  that  pseudarthrosis  with 
tapering  of  the  fragments  and  considerable  shortening  have  been  seen 
in  not  a  few  instances.  These  unfortunate  sequelae  are  due  partly  to 
non-recognition  of  the  injury  at  the  proper  time  and  the  consequent 
improper  treatment,  partly  to  confusion  with 
the  so-called  intrauterine  fractures  (congenital 
curvature).  (See  page  670.)  If  recognized  in 
time  and  treated  properly  from  the  outset,  an 
intrapartum  fracture  usually  heals  as  well  as 
one  sustained  later  in  childhood. 

Treatment. — The  danger  of  the  thin  skin  be- 
ing perforated  by  a  sharp  fragment  and  a  simple 
fracture  thus  becoming  compound,  urges  the 
greatest  care  in  transporting  and  undressing 
the  patient  ;  tight-fitting  clothing  should  be 
ripped  open  and  the  shoe  cut  open  up  the  side 
and  not  pulled  off  forcibly.  As  a  rule  the 
sooner  reduction  is  effected  the  more  easily 
and  certainly  coaptation  can  be  obtained.  In 
cases  of  marked  displacement  and  muscular 
contraction  hindering  reduction — for  example, 
in  oblique  fractures  in  well-developed  laborers 
— anaesthesia  is  advisable.  It  is  usually  stated 
that  the  foot  is  straight  if  the  prolongation  of 
the  inner  border  of  the  patella  passes  between 
the  first  and  second  toes  or  if  the  line  joining 
the  anterior-superior  spine  and  the  first  meta- 
tarsal touches  the  inner  border  of  the  patella. 
The  author  does  not  attach  too  great  value  to 
this  statement  as  gauging  by  the  eye  alone  may 
be  deceptive;  it  appears  more  important  to  compare  carefully  the  con- 
tour with  that  of  the  sound  limb. 

If  reliable  assistance  is  lacking — even  the  strength  of  the  best  of 
helpers  is  often  unavailing  or  gives  out  too  quickly — especially  if  anaes- 
thesia is  contraindicated,  Baudens'  extension  method,  as  modified  and 
described  recently  by  Kolaczek,  is  valuable  to  maintain  uniform  traction 
during  the  application  of  the  plaster-splint.  A  perineal  sling  is  attached 
to  the  head-post  of  the  bed;  a  piece  of  wood  the  length  and  breadth  of 
the  foot,  having  a  loop  of  sail-cloth  about  3  feet  long  laid  between  it 


Vulpius'  aluminum  splint, 
with  sliding  sections  and 
flexible  rod. 


FRACTURE  OF  THE  SHAFT  OF  THE  BONES  OF  THE  LEU.     677 

and  the  foot,  is  bandaged  to  the  sole  of  the  foot  and  the  ends  of  the 
sailcloth  tied  to  a  double  rope,  the  latter  being  fastened  to  the  door- 
handle or  other  fixture  and  tightened  by  twisting.    The  foot  is  supported 

and  the  traction  increased  till  the  shortening  is  overcome.  After  the 
plaster-splint  has  hardened  the  extension  is  removed. 

The  simpler  fixation  apparatus  of  wood,  tin,  wire,  straw  matting,  etc., 
used  for  transportation  and  fixation  during  the  first  few  days,  should 
be  removed  as  soon  as  the  conditions  permit  of  accurate  correction  and 
immobilization.  The  requisites  of  a  rational  method  are  only  met  by 
continuous  extension,  or  the  plaster-of-Paris  splint,  both  of  which  give 
satisfactory  results.  Continuous  extension,  as  recommended  especially 
by  Bardenhener  and  his  school,  to  be  effectual  requires,  according  to 
Wolff,  strict  observance  of  the  following  directions:  1.  Application  as 
early  as  possible.     2.  The  adhesive  plaster  strips  should  extend  well 


Fig.  427. 


v.  Volkmann's  splint  for  the  leg.     (Stimson.) 


above  the  fracture,  in  very  oblique  fractures  to  the  middle  of  the  thigh. 
3.  The  plaster  strips  should  be  applied  closely  at  the  ankle  with  the 
malleoli  padded,  not  separated  by  a  spreader.  4.  In  very  oblique  frac- 
tures 30  to  40  pounds  may  be  insufficient  and  even  60  or  70  be  required. 
5.  The  lower  fragment,  displaced  backward,  may  be  drawn  forward  by 
vertical  traction  of  about  fO  pounds  with  counterpressure  by  means  of 
a  20-pound  sand-bag  or  Bardenheuer's  loop  upon  the  upper  fragment. 
The  constant  supervision  required  by  the  extension  splint  usually 
makes  the  typical  plaster-splint  preferable  for  private  practice.  It  is 
also  the  one  most  used  in  hospitals,  and,  properly  applied,  gives  excellent 
results.  The  severe  circulatory  disturbance  or  even  gangrene  which 
has  occasionally  resulted  from  applying  a  plaster-splint  too  soon  or  too 
tightly,  has  led  the  majority  of  surgeons  to  advise  preliminary  immobili- 
zation in  a  Volkmann  T-splint  (Fig.  427),  or  v.  Brims'  position  splint 


.;:> 


INJURIES  OF  THE  LEO. 


(p.  543),  or  a  wire-splint,  the  plaster-splint  being  applied  at  the  end  of 
six  or  eight  days,  after  the  swelling  has  subsided.  The  following  points 
speak  for  early  or  immediate  immobilization  in  plaster:  1.  The  more 
recent  the  fracture  the  easier  and  more  complete  the  reduction.  2.  Fixa- 
tion in  a  tin-  or  wire-splint  does  not  prevent  the  displacement  due  to 
muscular  contraction  in  the  first  few  days,  so  that  anaesthesia  and  further 
reduction  are  necessary  in  applying  the  plaster-splint.  Accurate  palpa- 
tion of  the  fragments  is  also  hindered  by  the  swelling,  hence  the  control 
of  reduction  is  less  certain.  3.  The  earlier  the  immobilization  the  sooner 
the  discomfort  ceases,  especially  the  pain  caused  by  muscular  contraction 
due  to  rubbing  together  of  the  fragments.  If  the  correction  is  good  and 
the  splint  is  properly  applied,  the  patient  is  usually  free  from  pain  and 
remains  so  after  the  plaster  hardens.  4.  After  early  immobilization  the 
swelling  is  generally  slight,  as  the  hemorrhage  due  to  movements  of 
the   fragments    ceases.     The  danger  of   circulatory  disturbance,  which 

Fig.  428. 


Beely's  plaster-of-Paris  strip  splint  with  suspension  rings  for  fracture  of  the  leg. 


should  not  be  underestimated,  is  prevented  by  padding  the  limb  thinly 
with  cotton  and  a  soft  flannel  bandage  and  applying  the  plaster-splint 
loosely  or,  better,  by  using  instead  a  Beely  plaster-of-Paris  strip-splint. 
The  splint,  whether  strip  or  circular,  should  immobilize  the  ankle 
and  knee,  extending  from  the  toes  to  the  middle  of  the  thigh.  The  limb 
should  be  elevated  for  the  first  two  or  three  days  upon  pillows  or  by 
suspension.  'Fig.  42Vi  If  the  toes  become  blue,  cold,  numb,  and 
swollen,  the  splint  must  be  removed  under  all  circumstances;  hence 
careful  oversight  is  indispensable  during  the  first  few  flays.  It  is  well 
to  remove  the  splint  in  six  to  eight  days  for  inspection,  to  correct 
any  existing  deformity  and  to  apply  a  tighter  splint  to  meet  the  subsi- 
dence of  the  swelling.  Later  the  splint  is  renewed  at  intervals  of  two 
or  three  weeks,  the  limb  is  massaged  while  traction  is  maintained  upon 
the  foot,  and  the  knee  and  ankle-joint  are  moved  passively  at  the  latest 
after  the  second  change  of  splint.  As  soon  as  the  callus  is  firm,  not 
necessarilv  entirelv  ossified,  namelv,  after  the  fifth  week,  the  author 


FTiAcrrni:  of  the  shaft  of  the  iiosf.s  of  the  leg.    g79 


allows  the  patient  to  go  about  in  a  plaster-splint  till  union  is  complete; 
if  complete  bony  union  is  delayed,  a  removable  silicate-splint  may  be 
worn  extending  above  the  knee,  and  massage  and  passive  motion  applied 
every  time  it  is  removed. 

Recently  ambulant  treatment,  a  circular  plaster-splint  being  worn, 
has  been  preferred  by  many  surgeons  by  reason  of  the  warm  rec<  m- 
mendation  of  Krause,  Bardeleben,  Albers,  and  others.  After  the  swelling 
has  disappeared,  on  about  the  eighth  day,  the  splint  is  applied  directly 
upon  the  shaven  or  greased  skin.  v.  Brims'  portable  splint  is  also  used 
over  a  light  plaster-splint.  (Fig.  354,  p.  544.)  The  author  must  admit 
openly  that  so  far  he  has  not  been  able  to  convince  himself  of  the  much 
praised  advantages  of  this  method,  and  therefore  can  only  recommend 
it  for  cases  in  which  longer  rest  in  bed  would  be  dangerous  on  account 
of  existing  diseases  of  the  circulatory  or  respiratory  organs.  There  is 
also  the  possibility  of  recurrence  of  slight  displacement  by  this  method. 
In  the  absence  of  the  above  contraindications  he  regards  the  recumbent 
treatment  as  insuring  the  best  results.     In  the  rare  cases  in  which  in 

Fig.  429. 


Fenestrated  plaster  dressing.     (Stimson.) 


spite  of  all  care  the  reduction  was  only  partial  or  the  interposition  of 
soft  parts  or  their  impalement  could  not  be  overcome  without  operation, 
in  recent  years  an  incision  has  been  made  and  the  fragments  sutured 
in  place  with  excellent  results.  As  this  makes  the  greatest  demands 
upon  asepsis,  it  is  adapted  for  use  only  in  well-appointed  clinics  and 
hospitals,  and  should  be  limited  to  exceptional  cases. 

Compound  fractures  make  greater  claims  upon  the  care  and  technical 
ability  of  the  surgeon.  Recent  fractures  which  have  perforated  and 
made  only  a  small  skin-wound  may  usually  be  regarded  as  aseptic;  the 
wound  may  be  packed  temporarily  with  sterile  or  iodoform  gauze  while 
the  skin  is  carefully  cleaned  and  sterilized  from  the  foot  to  the  thigh; 
the  blood  is  squeezed  out  of  the  wound  and  the  latter  closed  with  an 
aseptic  dressing.  If  the  wound  is  very  small,  it  may  be  covered  with 
iodoform  or  sterile  gauze,  a  plaster-splint  can  be  applied  over  it,  and  the 
case  treated  like  a  simple  fracture. 

If  infection  is  suspected,  the  wound  is  widened  sufficiently  to  expose 
the  infected  parts,  especially  the  fragments,  all  blood-clots  and  loose 


(380  IXJUBIES  OF  THE  LEG. 

splinters  are  removed,  the  wound  cleansed,  soiled  or  badly  contused 
tissues  are  excised  and  the  cavity  drained,  or,  better,  packed  with 
iodoform  gauze.  If  infection  of  the  surfaces  of  the  fragments  is  suspected 
it  may  be  necessary  to  lay  gauze  between  the  fragments;  naturally 
they  have  to  be  coaptated  later.  If  the  surfaces  are  believed  to  be  clean, 
they  should  be  apposed  and  fixed  by  suturing  or  screwing  the  fragments 
together;  the  wound  is  drained  or  packed  down  to  and  about  the  frag- 
ments. A  thick  antiseptic  dressing  then  envelops  the  limb;  for  this 
purpose  "moss-pads"  can  be  used  with  advantage  as  they  fix  the 
fragments  well.  The  limb  is  then  bandaged  in  a  Volkmann  T-splint 
or  wire-splint.  If  only  a  slight  amount  of  discharge  is  anticipated  the 
author  generally  applies  a  plaster  splint  over  the  dressing  to  be  left  on 
eight  or  ten  days. 

The  case  should  be  watched  carefully  and  the  temperature  taken 
regularly.  If  there  is  no  fever,  if  the  wound  is  clean,  and  the  discharge 
slight,  the  drains  or  packing  can  soon  be  omitted  and  the  dressing  made 
smaller  and  a  plaster-splint  applied.  Otherwise  the  wound  must  be 
kept  open  and  any  infection  treated  on  general  principles.  The  tendency 
to  displacement  should  be  combated  as  much  as  possible,  but  generally 
cannot  be  entirely  prevented.  Later,  the  removal  of  necrotic  splinters 
or  resection  of  the  fracture  ends  to  give  better  coaptation  has  to  be 
considered. 

Amputation  or  exarticulation  is  not  nor  ever  will  be  entirely  dis- 
pensable in  cases  of  severe  contusion  and  laceration  of  the  leg,  especially 
of  the  soft  parts  and  large  vessels.  General  rules  cannot  be  given  as 
to  the  indications  for  these  operations  in  such  injuries.  Such  procedures 
will  be  limited  or  extended  according  to  personal  experience  and  skill 
and  the  conditions  under  which  treatment  has  to  be  conducted.  Asepsis 
enables  us  at  the  present  time  to  greatly  extend  the  application  of  con- 
servative measures  in  the  treatment  of  gunshot  fractures  with  small  skin 
wounds. 

FRACTURES  OF  THE  TIBIA  OR  FIBULA. 

Fracture  of  the  tibia  or  fibula  alone  is  not  frequent;  according  to 
v.  Bruns  it  represents  only  2  per  cent,  of  all  fractures. 

Fracture  of  the  shaft  of  the  tibia  alone  is  rare,  because  the  fibula  is 
not  able  to  bear  the  weight  of  the  body  at  the  moment  of  fracture,  and 
so  breaks.  W nat  has  been  said  in  discussing  fractures  of  both  bones 
applies  to  fractures  of  the  tibia,  except  that  any  displacement  is  slight 
or  absent  and  no  deformity  is  produced  by  lifting  the  leg,  as  the  fibula 
acts  as  a  sort  of  splint.  Exceptionally  there  are  marked  lateral  displace- 
ment and  inflexion  due  to  continuation  of  the  direct  violence;  under 
certain  circumstances  the  reduction  of  such  a  displacement  may  be  very 
difficult.  Usually  there  is  immediate  complete  loss  of  function;  excep- 
tionally in  the  case  of  transverse  fractures  with  interlocked  serrations 
the  patient  may  be  able  to  walk  a  few  steps  if  the  pain  can  be  endured. 
The  treatment  is  aided  bv  the  integrity  of  the  fibula. 


DISLOCATION  OF  THE  FIBULA.  681 

Fractures  of  the  fibula  in  the  middle  third  arc  caused  almost  exclu- 
sively by  direct  violence,  run  almost  transversely,  and  have  little  tendency 
to  displacement  on  account  of  the  thick  muscular  covering  and  the 
splint  action  of  the  tibia.  For  the  same  reason  it  is  often  difficult  to 
elicit  typical  symptoms  of  fracture,  the  diagnosis  depending,  aside  from 
the  nature  of  the  violence,  chiefly  upon  the  fracture  pain.  One  spot  is 
always  particularly  tender  on  pressure,  and  pain  is  produced  by  pressing 
both  bones  together  at  a  distance  from  the  point  of  injury;  this  is  due 
to  the  rubbing  of  the  surfaces  upon  each  other  and  crepitus,  although 
slight,  can  often  be  obtained.  If  the  pain  can  be  borne,  walking  is 
usually  possible.  The  fracture  unites  in  four  or  five  weeks  under  any 
kind  of  retention  splint. 

At  the  upper  end  of  the  fibula  fractures  are  caused,  aside  from  direct 
violence,  by  muscular  traction;  for  example,  one  sees  numerous  instances 
of  fracture  of  the  head  of  the  fibula  due  to  violent  contraction  of  the 
biceps;  as  a  rule  this  action  is  associated  with  simultaneous  forcible 
adduction  of  the  leg,  due  to  direct  violence.  The  fracture  is  interesting 
chiefly  on  account  of  the  associated  injury  of  the  peroneal  nerve,  which 
passes  forward  around  the  neck  of  the  fibula.  The  nerve  may  be  torn, 
transfixed,  or  contused  by  the  fragments  or  enclosed  and  constricted 
later  by  callus.  The  head  of  the  fibula  projects  outward  unduly,  is 
drawn  up  during  active  flexion  of  the  knee  by  the  biceps  and  sinks 
back  during  extension;  below  it  can  be  felt  a  depression  and  in  this  the 
upper  end  of  the  shaft.  After  reducing  the  fragments  the  limb  can  be 
put  up  in  almost  any  splint  which  will  hold  the  knee  slightly  flexed. 
Partial  or  complete  paralysis  of  the  peroneal  nerve  indicates  the  use  of 
electricity,  massage,  and  baths;  if  these  fail  to  act,  the  nerve  should 
be  exposed  and  sutured,  or  freed  from  any  constricting  cicatrix  or 
callus. 

In  the  lower  third  the  fibula  breaks  separately  at  a  characteristic  point 
2  to  2\  inches  above  the  outer  malleolus,  or  in  connection  with  dislo- 
cation or  sprain  of  the  ankle-joint,  or  from  direct  violence.  The  frag- 
ments are  usually  displaced  more  or  less  ad  axin,  forming  an  obtuse 
angle  opening  outward.  The  foot  is  slightly  everted  (flat-foot  position). 
The  treatment  will  be  considered  under  injuries  of  the  ankle-joint. 


DISLOCATION  OF  THE  FIBULA. 

Of  total  upward  dislocation  of  the  fibula,  namely,  in  both  joints,  3 
cases  have  been  published  in  the  literature  by  Roger,  Stromeyer,  and 
Sorbets.  They  were  caused  by  violence  acting  from  below  upon  the 
outer  edge  of  the  foot.  Dislocation  at  the  upper  tibiofibular  joint  has 
been  often  seen  as  the  result  of  disturbances  in  growth  following  acute 
osteomyelitis.  If  the  growth  of  the  tibia  is  checked,  the  head  of  the 
fibula  advances  upward;  the  reverse  follows  if  the  growth  of  the  fibula 
is  retarded  or  that  of  the  tibia  increased.  Looseness  of  the  joint  and 
displacement    backward    or   forward    follows    inflammatory    processes 


682  INJURIES  OF  THE  LEG. 

rather  often,  especially  chronic  serous  inflammation  of  the  tibiofibular 
joint  transmitted  from  the  knee. 

Traumatic  dislocation  of  this  joint  is  very  rare.  Hirschberg  saw  10 
cases  of  this  sort,  dislocated  upward  with  simultaneous  oblique  fracture 
of  the  upper  third  of  the  tibia,  but  only  2  with  fracture  of  the  fibula 
below  the  head.  Nine  cases  of  forward  dislocation  of  the  head  and  4 
of  backward  dislocation  without  fracture  have  been  reported;  the  dislo- 
cation forward  was  only  once  due  to  direct  violence,  in  the  other  instances 
it  was  the  result  of  falling  or  slipping,  the  patient  forcibly  contracting 
the  muscles  arising  from  the  front  of  the  fibula,  the  extensor  communis 
digitorum,  extensor  hallucis  longus,  and  the  peronei,  to  check  the  fall. 
Simple  backward  dislocation  is  referred  chiefly  to  the  traction  of  the 
biceps. 

In  forward  dislocation  the  limb  is  held  extended,  the  foot  adducted; 
the  patient  cannot  stand  but  can  move  the  leg  while  sitting.  In  the 
region  of  the  peroneal  nerve  tingling  and  numbness  are  present.  At 
the  outer  side  of  the  tibial  spine  the  dislocated  head  can  be  seen  and 
felt  projecting  abnormally  with  the  biceps  tendon  curving  forward 
to  it. 

In  backward  dislocation  the  limb  is  held  flexed  and  the  head  of 
the  fibula  can  be  felt  and  moved  behind  its  normal  position.  Reduc- 
tion is  essentially  by  direct  pressure.  Retention  requires  fixation  for 
two  or  three  weeks  in  a  splint,  in  the  case  of  backward  dislocation 
preferably  with  the  knee  slightly  flexed  to  relieve  the  traction  of  the 
biceps. 

Dislocation  at  the  lower  tibiofibular  joint  without  other  injuries  is  very 
doubtful;  its  occurrence  with  fracture  and  dislocation  of  the  ankle  will 
be  discussed  later. 


PSEUDARTHROSES   OF  THE  LEG. 

Pseudarthrosis  from  fracture  is  seen  chiefly  after  intra-uterine,  intra- 
partum fractures  or  those  occurring  in  early  childhood  In  adults  it 
may  be  the  sequel  of  very  oblique  fractures,  of  marked  displacement 
(Fig.  430),  of  interposition  of  the  soft  parts,  and  especially  of  compound 
comminuted  fractures  in  which  large  splinters  are  free  or  are  thrown 
off  later  as  the  result  of  suppuration.  It  not  infrequently  follows  necrosis 
of  the  tibia  due  to  osteomyelitis,  either  on  account  of  insufficient  bone 
production  after  necessarily  early  removal  of  a  sequestrum  or  as  the 
result  of  destruction  of  the  new  bone  by  suppuration.  The  mobility  of 
the  false  joint  varies  according  to  the  amount  of  bone  destroyed  and 
the  tapering  of  the  fragments,  which  in  children  is  often  very  pro- 
nounced. 

If  due  merely  to  delayed  union  in  connection  with  only  moderate 
displacement,  recovery  is  usually  possible  in  adults — although  perhaps 
requiring  months — by  the  use  of  conservative  measures — namely,  by  the 
wearing  of  a  portable  well-fitting  plaster-  or  silicate-splint;  by  Bier's 


VSEU1)  ARTHROSES  OF  THE  LEG. 


683 


Fig.  430. 


congestion-hyperaemia,  the  tourniquet  being  applied  about  the  thigh 
|  Dumreicher,  Helferich);  by  massage,  painting  energetically  with  iodine, 
or  injecting  a  few  drops  of  tincture  of 

iodine,  or   alcohol,  or   lactic   acid   into 
the  callus. 

Operation  is  to  be  considered  for 
older  pseudoarthroses  in  young  chil- 
dren, for  large  defects  of  bone,  and 
those  cases  in  which  the  above  treat- 
ment fails.  The  pseudarthrosis  is  ex- 
posed, the  fibrous  tissue  between  the 
stumps  excised,  the  latter  freshened  up 
transversely,  or  rabbeted  and  fastened 
together  with  sutures  or  screws.  Even 
after  careful  operation  the  prognosis 
is  unfortunately  often  made  unfavor- 
able by  lack  of  growth  of  the  perios- 
teum. The  operation  then  has  to  be 
repeated  or  irritants  tried.  If  the 
intact  fibula  prevents  the  approxima- 
tion of  the  stumps  of  the  tibia  wheie 
the  defect  is  large,  it  may  be  neces- 
sary to  excise  part  of  the  fibula ;  on 
account  of  the  resulting  shortening  it 
is  better,  however,  to  do  a  plastic 
operation.  Halm  transplanted  the 
upper  end  of  the  tibia  upon  the  lower 
stump  of  the  divided  fibula  with  suc- 
cess. Poirier  recently  reported  a  sim- 
ilar case  ;  with  the  .r-ray  he  watched 
the  implanted  fibula,  stimulated  by 
use,  grow  to  two-thirds  the  size  of  the 
tibia  in  three  years.  In  appropriate 
eases  the  defect  may  be  filled  in  by 
the  Konig-Miiller  method  of  implanting  a  flap  of  skin,  periosteum,  and 
bone  from  one  or  both  fragments ;  it  has  been  successful  in  many  in- 
stances.. If  all  other  means  fail,  a  supporting  apparatus  must  be  worn 
or  amputation  be  performed. 


Pseudarthrosis  of  the  leg.     (v.  Bruns.) 


CHAPTER   XXXIV. 

DISEASES  OF  THE  LEG. 
INFLAMMATORY   PROCESSES  AND  ULCERS  OF  THE  SOFT  PARTS. 

Furuncle  of  the  skin  on  the  hairy  parts  of  the  leg,  inflammation  of 
the  skin  and  subcutis  around  small  infected  contused  wounds,  abrasions, 
scratches,  etc.,  are  extremely  frequent  affections,  and  lymphangitis  and 
erysipelas  are  not  uncommon  after  such  lesions.  Deep  phlegmon  may 
be  due  to  suppuration  in  the  foot  which  is  transmitted  upward  along 
the  tendon  sheaths  or  lymphatics;  it  is  also  seen  as  a  local  manifestation 
of  infected  compound  fractures,  purulent  periostitis  or  osteomyelitis  of 
the  bones  of  the  leg,  and  occasionally  it  occurs  primarily  as  a  periphlebitis 
about  thrombosed  and  suppurating  varicosities.  In  the  latter  case  the 
avenue  of  infection,  whether  solely  through  the  blood  or  not,  can  seldom 
be  determined. 

All  these  inflammations  have  nothing  uncommon  about  them,  and 
are  treated  on  general  principles.  But  they  have  one  peculiarity, 
namely,  that  the  circulation  in  the  leg  in  the  vertical  position  is  less 
favorable  to  recovery;  so  it  happens  that  in  the  absence  of  pain  the 
patient  often  cannot  be  kept  in  bed,  and  a  slight  and  insignificant  injury 
remains  unhealed  and  thus  gives  rise  to  the  production  of  chronic  ulcers. 

Of  the  chronic  inflammations,  two  especially  claim  the  surgeon's 
interest,  chronic  eczema  and  ulcer,  the  latter  the  cross  of  all  hospitals, 
and  ill-famed  from  past  ages  on  account  of  its  frequency  and  obstinacy. 
The  common  cause  of  their  frequency  lies  in  the  unfavorable  local  con- 
ditions of  the  circulation  and  improper  care  and  lack  of  cleanliness. 
The  circulatory  disturbance  produced  by  varicosities  is  responsible  for 
the  fact  that  the  above  conditions  are  found  so  frequently,  in  about  half 
the  cases,  with  varicose  veins.  A  slight  abrasion  of  the  skin  from  a 
blow,  the  chafing  of  a  boot  or  scratching,  etc.,  combined  with  uncleanli- 
ness,  leads  to  the  development  of  a  slight  superficial  inflammation  of  the 
surrounding  skin  which  heals  over  finally  with  a  delicate  eschar;  the 
latter,  especially  if  situated  over  the  anterior  border  of  the  tibia  or 
adherent  to  it,  is  easily  injured,  infected,  and  becomes  ulcerated;  if  the 
process  is  repeated  at  intervals,  an  ulcer  is  formed  with  thick  infiltrated 
base  and  walls  and  little  tendency  to  heal,  the  putrefying  pus  producing 
a  simple  papular  or  vesicular  eczema  of  the  surrounding  skin;  in  other 
instances  the  eczema  is  primary,  and  is  irritated  and  infected  by  scratch- 
ing and  so  leads  to  the  formation  secondarily  of  an  ulcer.  Or  the  ulcer 
may  be  due  to  rupture,  or  inflammation  and  perforation  of  a  thrombosed 
varicose  vein ;  also  to  a  fistula  from  a  sequestrum  caused  by  osteomye- 
litis. 

(  084  ) 


INFLAMMATORY  PROCESSES  AND  ULCERS  OF  SOFT  PARTS.     685 


Fig.  431. 


In  spite  of  the  manifold  causes  the  further  development  of  the 
ulcer  is  usually  uniform  in  all  cases.  With  proper  and  sufficient  treat- 
ment recovery  is  possible;  but  the  unfavorable  social  relations,  the 
ignorance  and  carelessness  of  the  patients,  most  of  whom  belong  to 
the  laboring  classes,  often  prevent  successful  treatment.  Before  the 
cicatrix  is  solid  or  even  complete  it  is  exposed  to  the  same  injurious 
influences,  and  the  result  is  an  acute  exacerbation  and  gradual  steady 
advance  of  the  process.  The  recurring  inflammation,  the  consequent 
thrombosis  of  the  lymphatics,  the  congestion  due  to  the  varicose  veins 
all  lead  to  an  advancing  plastic  infiltration  of  the  soft  parts,  not  only  a 
serous  inflammation,  but  a  cellular  deposit,  a  new  growth  of  connective 
tissue  with  dense  thickening  of  the  skin  and  subcutis,  the  latter  becoming 
adherent  to  the  muscles,  tendons,  and  even  the  bone,  and  the  irritation 
penetrating  deeper  causes  chronic  inflamma- 
tion in  the  tendon-sheaths,  periosteum,  and 
joints,  adhesions  between  the  tendons  and  their 
sheaths,  the  formation  of  periosteal  exostoses, 
and  stiffness  of  the  joint.  The  muscles  often 
atrophy  at  an  early  date,  partly  as  the  result 
of  the  circulatory  disturbance,  partly  of  in- 
flammation and  of  disuse.  Flat-foot  is  there- 
fore a  frequent  result ;  exceptionally  an  inflam- 
matory contracture  can  lead  to  the  development 
of  a  club-foot. 

The  ulcer  is  commonly  situated  in  the  lower 
third  or  at  the  junction  of  the  lower  and 
middle  third  of  the  leg,  although  its  seat,  size, 
and  form  may  vary  greatly.  It  is  often  found 
over  or  behind  one  of  the  malleoli,  a  spot  the 
size  of  a  lentil,  insignificant  but  extremely 
stubborn,  the  edges  irregular  and  red,  the 
surrounding  skin  bluish-red  and  filled  with  a 
thick  network  of  fine  varicose  veins.  This 
form  is  often  very  painful.  In  other  cases  one 
or  more  flabby,  granulating  spots  from  f  to  1 
inch  in  diameter,  are  situated  over  the  front 
surface  of  the  tibia  and  extend  down  to  the 
bone,  the  irregular  edges  being  ulcerated,  the 
surrounding  skin  indurated,  immovable,  red- 
dish-brown or  brown  in  spots,  often  warty, 
covered  with  thick  scales;  the  base  of  the  ulcer 
is  covered  with  flabby  discolored  granulations 
secreting  a  thin,  foul-smelling  pus.  In  still 
other  instances  the  ulcer  encircles  the  leg; 
below  it  the  foot  and  leg  are  then  more  or  less  thickened  as  in 
elephantiasis,  and  with  the  stiffened  ankle-joint  serve  to  form  a  sort 
of  "living  stilt."     (Fig.  431.) 

Chronic  eczema  of  the  leg,  with  or  without  ulcer,  is  apt  to  be  of  the 


Circular  ulcer  of  the  leg.  with 
elephantiasis  of  the  foot.  (v. 
Bruns.) 


686  DISEASES  OF  THE  LEG. 

squamous  variety;  the  hypertrophic  superficial  epithelium  may  come 
off  in  small  dry  scales,  or  the  skin  is  of  a  bluish-red  or  brownish  color 
and  casts  off  large  scales  or  crusts  which,  glued  to  the  epithelium  by  the 
secretion,  are  easily  picked  off,  exposing  the  reddened,  moist,  and  glisten- 
ing corium  beneath. 

Syphilitic  ulcers  are  not  rare  on  the  leg  and  are  important.  In  some 
instances  the  surgeon  is  dealing  with  a  secondary  eruption,  in  others 
with  a  degenerated  gumma,  the  latter  often  from  the  periosteum  of  the 
tibia.  The  ulcers  have  the  characteristic  specific  appearance,  the 
sharp-cut  edges  and  bacon-like  membrane,  and  are  usually  easily 
recognized  as  syphilitic.  Their  specific  nature  is  also  often  indicated 
by  their  being  situated  on  the  upper  part  of  the  leg,  occasionally  on  the 
calf,  while  the  lower  part  of  the  leg  is  free,  although  the  common  ulcer 
occurs  here  also,  but  rarely.  As  a  rule  they  heal  rapidly  under  specific 
treatment.  From  the  effect  of  other  conditions  upon  them,  especially 
varicose  veins,  they  may  assume  the  character  of  ordinary  varicose 
ulcers. 

Prognosis. — The  prognosis,  aside  from  the  possibilities  given,  may 
become  serious  if  an  epithelial  carcinoma  develops  in  the  ulcer,  a  not 
infrequent  occurrence;  it  should  be  remembered  that  the  walls  of  a 
benign  ulcer  may  arouse  suspicion  of  malignancy  and  present  difficulties 
even  in  microscopical  diagnosis.  Complications,  lymphangitis,  erysipe- 
las, etc.,  are  rather  frequent. 

Treatment. — The  extensive,  almost  endless  literature  upon  the  treat- 
ment of  chronic  ulcer  of  the  leg  and  the  constant  recommendation  of 
new  remedies  show  very  clearly  the  thanklessness  of  treatment  and 
the  poor  prospect  of  permanent  cure.  Too  often  it  is  impossible  to 
maintain  the  conditions  essential  to  recovery,  absolute  cleanliness  and 
improved  circulation.  Whenever  it  is  possible  therefore  the  author 
keeps  the  patient  in  bed  with  the  limb  slightly  elevated,  not  only  till 
cicatrization  is  complete,  but  also  until  it  has  become  fairly  solid.  This 
often  means  overcoming  the  objections  of  the  patient,  who  is  only  too 
much  inclined  to  stand  or  sit  up  for  a  few  hours  as  soon  as  the  condition 
improves  and  the  pain  ceases,  or  who  is  unable  for  social  reasons  to  give 
the  limb  the  necessary  rest  and  protection.  Without  denying  that  the 
ambulant  treatment  may  be  successful  under  circumstances,  nevertheless 
the  conditions  for  rapid  recovery  given  by  the  recumbent  position  are 
incomparably  more  favorable. 

The  limb  is  washed  thoroughly  with  soap  and  hot  water,  shaved,  and 
sterilized  the  same  as  for  operation.  The  ulcer  is  dried  off  with  sterile 
gauze,  a  wet  dressing  of  2  per  cent,  aluminum  acetate  is  applied  to  the 
entire  leg,  and  covered  with  rubber  tissue  and  a  retention  bandage. 
This  dressing  should  be  renewed  two  or  three  times  daily  at  first,  later 
once  a  day,  the  skin  about  the  ulcer  each  time  being  cleaned  and  the  fat 
removed  with  ether.  Outside  of  hospital  practice  it  is  simpler  to  wash 
the  leg  two  or  three  times  daily  for  ten  to  fifteen  minutes  with  soap  and 
warm  water,  to  dry  it,  and  apply  a  wet  dressing  of  half  strength  lead 
subacetate  which  is  renewed  three  or  four  times  daily.     By  this  method, 


TNFLAMMA  TOBY  PROCESSES  AND  ULCERS  OF  soft  PARTS.     687 

which  is  simple,  cheap,  and  therefore  suitable  for  practice  among  the 
poor,  the  secretion  diminishes  rapidly  and  the  ulcers  become  covered 
with  clean  granulations,  presupposing  always  that  the  limb  is  kept 
elevated.  After  the  nicer  has  become  clean  an  ointment  promotes  the 
growth  of  skin. 

Dusting  powders  of  iodoform,  dermatol,  orthoform,  bismuth,  naph- 
thalin,  antinosin,  etc.,  have  been  used  considerably  to  allay  the  itching. 
The  author  has  never  found  any  particular  advantage  in  this  method; 
the  ulcers  usually  become  clean  more  rapidly  under  moist,  warm, 
antiseptic  compresses.  The  powders  may  be  used  to  prevent  putre- 
faction, also  if  moist  warmth  is  not  well  borne,  or  for  ambulant  treat- 
ment. Naphthalin  is  good  for  sluggish  ulcers,  as  it  is  very  stimulating; 
but  as  it  causes  burning  pain,  increased  secretion,  and  bleeding,  it 
should  be  discontinued  as  soon  as  the  ulcer  is  clean.  Orthoform  is 
occasionally  useful  in  diminishing  the  pain  of  the*so-ealled  erethistic 
ulcers.  Dusting  with  calomel  and  moistening  with  salt  solution  are 
very  effectual,  and  have  been  recommended  again  recently.  The 
silver  nitrate  stick,  8  per  cent,  zinc  chloride  solution,  tincture  of  iodine 
and  balsam  of  Peru  are  sometimes  beneficial. 

The  essential  of  ambulant  treatment  is  a  good  bandage  to  prevent 
congestion.  After  careful  cleansing  of  the  leg  and  ulcer  the  latter  may 
be  covered  with  iodoform  gauze,  an  ointment  of  2  per  cent,  silver  nitrate, 
20  per  cent,  borovaseline,  or  ointment  of  the  red  oxide  of  mercury,  etc.; 
over  this  a  thin  pad  of  cotton  and  the  leg  then  bandaged  tightly  from 
the  toes  to  the  knee  with  a  3^  to  4-inch  flannel  roll  bandage;  the  dress- 
ing is  renewed  morning  and  evening.  The  skill  and  care  required  to 
apply  the  bandage  smoothly  and  firmly  is  unfortunately  often  absent 
among  the  laboring  classes,  the  ones  chiefly  affected.  Binding  the  leg 
with  a  thin  rubber  roll  bandage  applied  directly  over  the  skin  and 
-the  ulcer,  as  suggested  by  Martin  in  America,  is  even  better.  The  roll 
is  put  on  smoothly  but  not  tightly;  in  walking  the  leg  swells,  so  that  a 
uniform  pressure  is  established;  as  the  rubber  prevents  evaporation,  it 
acts  like  a  wet  compress,  stimulating  the  granulation  but  often  also 
producing  eczema  around  the  ulcer.  The  bandage  has  to  be  washed 
carefully  with  soap  and  cold  water  at  night  and  kept  clean.  Guerin's 
cotton  dressing,  recommended  in  Germany  by  v.  Volkmann,  is  little 
used.  The  same  applies  to  Baynton's  method  of  strapping  with  thin 
adhesive-plaster  strips. 

Unna's  zinc  oxide  gelatin  dressing  is  very  good  and  has  been  well 
tested;  Heidenhain  recommends  the  following:  warm  foot-bath  for 
fifteen  to  thirty  minutes,  during  which  the  limb  is  rubbed  with  soft 
soap  and  lint  or  cotton.  Dry.  Sterilization  with  1 :  1000  bichloride; 
the  ulcer  itself  is  merely  patted  gently  with  the  solution.  The  skin  and 
all  spots  of  eczema  are  smeared  thickly  with  Lassar's  paste,  the  ulcer 
dusted  with  iodoform  and  then  smeared  over  with  red  precipitate  oint- 
ment and  covered  with  sterile  gauze  if  the  discharge  is  profuse.  The 
limb  is  then  painted  from  the  toes  to  the  knee  and  behind  to  above  the 
knee,  with  Unna's  zinc  gelatin  (zinc  oxide,  gelatin,  aa  20  parts;  glycerin, 


688  DISEASES  OF  THE  LEG. 

water,  aa  SO  parts)  warmed,  and  covered  with  a  starched  bandage  to  the 
knee,  then  repainted  with  gelatin,  etc.,  until  four  layers  of  gauze  have 
been  applied;  the  whole  is  then  bandaged  with  a  muslin  roll.  The 
dressing  becomes  hard  and  dry  in  twenty-four  hours.  If  there  is  much 
discharge,  the  dressing  should  be  renewed  every  three  days,  later  every 
two  to  four  weeks,  in  general,  as  soon  as  the  discharge  soaks  through; 
at  each  change  careful  cleansing  and  sterilization. 

Although  these  dressings  allow  the  patients  to  go  about  their  work 
during  the  entire  treatment,  nevertheless  the  author,  in  view  of  his 
experience,  is  compelled  to  enforce  continuous  elevation  of  the  limb  till 
cicatrization  is  complete,  if  possible,  and  only  uses  the  above  methods 
later,  after  the  ulcer  has  skinned  over. 

Nussbaum  recommends  excision  of  the  ulcer  down  to  the  fascia  for 
old,  sluggish  indurated  ulcers.  Occasionally  it  is  beneficial  to  excise 
the  edges,  with  or  "without  scraping  the  base.  Recently  skin-grafting 
has  been  preferred,  and  has  effected  rapid  recovery  even  in  the  case  of 
large  ulcers. 

Thiersch  grafts  require  an  aseptic  surface,  and  should  therefore  not 
be  applied  until  the  granulations  are  clean.  The  attempt  to  clean 
them  by  scraping  and  sterilizing  almost  always  fails;  on  the  other  hand, 
by  waiting  till  the  ulcer  is  clean,  it  may  be  scraped  without  sterilizing. 
Gauze  is  then  applied  till  the  bleeding  stops,  after  which  the  grafts  are 
spread  over  the  entire  surface.  Transplantation  upon  a  scraped  and 
freshened  surface  always  takes  better  than  upon  granulation-tissue. 
As  the  grafted  skin  is  always  delicate  and  easily  injured,  the  leg  should 
be  wrapped  in  cotton  and  elevated  for  two  or  three  weeks,  and  later 
when  the  patient  is  up,  protected  by  a  dressing,  preferably  L  nna's. 

Krause  recommends  grafting  with  pieces  of  whole-skin  without  the 
subcutaneous  fat;  Hirschberg  advises  leaving  the  latter.  If  they  take — 
which  happens  less  frequently  than  with  Thiersch  grafts — they  become 
slightly  discolored  but  live,  and  give  in  fact  better  protection  than  the 
latter.  In  choosing  between  the  two  methods,  the  possibility  of  the 
failure  of  Krause's  or  Hirschberg's  method  should  be  remembered;  and, 
further,  that  the  spot  from  which  the  graft  was  taken,  unless  closed  by 
suture,  heals  more  slowly  than  that  shaved  for  the  Thiersch  graft. 
The  Italian  method  goes  a  step  farther  than  either  of  the  two  in  forming 
a  pedunculated  flap  from  the  other  extremity,  and  is  in  fact  more  certain 
and  prevents  recurrence  better  than  the  other  methods.  As  the  skin  of 
the  other  limb  is  rarely  healthy  in  the  case  of  patients  with  chronic 
ulcers,  the  method  is  more  adapted  to  the  covering  in  of  traumatic 
defects  of  the  skin  of  the  ankle  or  heel.  Ligation  of  the  saphenous 
vein,  which  is  employed  successfully  at  the  present  time  to  improve  the 
circulation  in  cases  of  varicose  ulcers,  will  be  described  later.  Bardescu 
and  Chipault,  in  order  to  hasten  and  facilitate  the  healing  of  varicose 
ulcers,  recommend  stretching  the  nerves  supplying  the  area  involved, 
namely,  either  the  internal  or  external  saphenous,  the  peroneal,  or  the 
musculocutaneous,  and  report  good  results.  The  author  cannot  give 
any  personal  experience  in  this  respect.     Mariani  speaks  in  high  terms 


ANEURISMS  IN  Tin:  LEG. 

of  the  radical  cure  obtained  by  circular  incision  of  the  skin  and  division 
of  all  subcutaneous  vessels  down  to  the  fascia  at  a  point  above  the  ulcer. 

The  after-treatment  should  aim  to  prevent  recurrence  by  protecting 
the  cicatrix  with  an  appropriate  dressing,  to  mobilize  the  cicatrix  upon 
the  underlying  tissues,  and,  above  all,  to  overcome  any  stiffness  of  the 
ankle  by  massage  and  careful  passive  and  active  motion.  With  a  stiff 
ankle,  especially  in  the  pes  equinus  position,  the  danger  of  recurrence  is 
very  great.  In  the  very  severe  cases  of  old  large  ulcers  extending 
around  the  leg  and  bordered  with  indurated  diseased  skin,  even  though 
this  skin  is  not  ulcerated,  it  is  usually  best  to  amputate  the  leg,  especially 
if  there  are  elephantiatic  thickening  of  the  foot  and  leg  and  stiffness  of 
the  ankle.  Such  patients  are  much  better  off  with  a  wooden  than  a 
diseased  leg;  they  are  thus  freed  from  the  chronic  suppuration  and  its 
evil  consequences,  and  are  better  able  to  work  and  support  themselves. 


ANEURISMS  IN  THE  LEG. 

Aneurism  of  the  arteries  of  the  leg  is  much  less  frequent  than  aneurism 
of  the  popliteal  artery.  In  a  recent  article  Vezes  could  only  collect  91 
cases  from  the  literature — among  these,  5  arteriovenous  aneurisms,  in 
which  the  anterior  and  posterior  tibial  arteries  were  divided  about 
equally;  the  peroneal  was  seldom  affected  alone,  but  the  lower  part 
of  the  popliteal  (truncus  tibioperoneus)  somewhat  more  often.  The 
majority  of  aneurisms  were  traumatic,  following  puncture  or  shot- 
wounds,  and  rather  frequently  fractures  of  the  tibia.  In  the  latter  case 
the  tumor  in  some  instances  made  its  appearance  immediately  after  the 
injury,  presumably  as  the  result  of  impalement  or  laceration  of  the 
wall  of  the  vessel  by  a  sharp  fragment;  in  others  it  appeared  later  after 
gradual  erosion  of  the  vessel;  exceptionally  after  removal  of  the  splint. 
A-  a  rule  traumatic  aneurisms  enlarge  rapidly,  the  diffuse  infiltration 
of  blood  into  tissues  about  the  sac  soon  causing  severe  circulatory 
disturbances,  occasionally  gangrene  of  the  foot. 

Symptoms. — The  symptoms  are  indefinite  as  long  as  the  tumor  is 
concealed  beneath  the  thick  muscles,  namely,  vague,  spasmodic  radi- 
ating pains,  paresthesias,  pareses,  dilatation  of  the  veins  of  the  foot, 
oedema  of  the  ankle.  The  diagnosis  becomes  positive  as  soon  as  the 
increasing  tumor  gives  pulsation  and  a  bruit,  and  disappears  on  com- 
pressing the  femoral  artery.  Large  blood-clots  in  the  sac  may  render 
the  pulsation  indistinct.  The  condition  is  mistaken  chiefly  for  an 
abscess  or  for  sarcoma  of  the  bone.  Confusion  is  usually  avoidable  if 
these  possibilities  are  remembered. 

Treatment. — In  the  case  of  recent  traumatic  aneurisms  the  injured 
vessel  should  be  explored  under  application  of  the  Esmarch,  the  clots 
removed,  and  the  vessel  ligated  above  and  below  as  soon  as  possible 
to  prevent  severe  circulatory  disturbance  and  gangrene.  For  spon- 
taneous or  older  traumatic  aneurisms  the  methods  described  under 
aneurism  of  the  popliteal  artery  may  be  tried.  Constriction  of  the 
Vol.  Ill— 44 


690  DISEASES  OF  THE  LEG. 

limb  by  means  of  an  elastic  bandage  leaving  the  aneurism  free,  com- 
pression of  the  femoral  artery,  and  ligation  above  the  aneurism,  have  all 
given  some  successful  results.  In  contrast  to  these  successes  stand  a 
large  number  of  failures:  non-recovery,  recurrence,  gangrene,  death. 
In  view  of  modern  asepsis  the  author  is  more  inclined  to  advise  radical 
operation  at  the  outset,  either  extirpation  of  the  sac  or  the  operation  of 
Antyllus.  Although  the  number  of  cases  of  successful  extirpation  is 
still  too  small  to  be  of  value  statistically,  the  few  favorable  results  known 
are  encouraging.     (See  Popliteal  Aneurism.) 


VARICOSE  VEINS  OF  THE  LEG. 

Diseases  of  the  veins  of  the  leg,  especially  dilatation,  are  more  frequent 
than  diseases  of  the  arteries,  the  so-called  varices  being  typical  of  dilata- 
tion of  the  veins  in  general.  In  spite  of  the  great  frequency  of  varicosities, 
their  etiology  is  still  rather  obscure.  Mechanical  factors  preventing  the 
return  of  venous  blood  certainly  play  an  important  part;  regarded  as 
such  are  certain  valvular  insufficiencies  of  the  heart,  abdominal  tumors, 
especially  pregnancy,  the  wearing  of  tight  garters,  tumors  at  a  higher 
level — in  view  of  the  height  of  the  blood-column  thus  pressing  upon  the 
venous  valves,  and  hard  work  combined  with  long  periods  of  standing. 
But  these  factors  alone  are  not  a  sufficient  explanation;  there  is  no 
doubt  that  pregnancy  greatly  favors  the  production  of  varicosities,  but 
that  the  gravid  uterus  is  not  always  the  essential  cause  in  preventing 
the  return  of  venous  blood  is  proved  by  many  cases  in  which  the  vari- 
cosities developed  to  a  considerable  size  in  the  first  months  of  pregnancy 
when  there  could  be  no  question  of  pressure  of  the  uterus  upon  the 
abdominal  veins  or  of  any  considerable  increased  intra-abdominal 
pressure.  On  the  contrary,  large  abdominal  tumors  attended  by  marked 
intra-abdominal  tension  are  not  infrequently  unaccompanied  by  varicose 
veins.  These  mechanical  factors  therefore  can  be  only  accorded  a 
co-operative  significance;  the  actual  causes  leading  to  atrophy  of  the 
walls  or  of  the  valves  of  the  veins  and  to  dilatation  are  unknown.  It 
is  certainly  not  the  atrophy  of  old  age,  as  the  disease  usually  develops 
between  the  twentieth  and  fortieth  year,  often  soon  after  puberty,  and 
only  in  few  cases  after  middle  life.  In  the  etiology  a  certain  significance 
is  attached  to  inherited  and  racial  peculiarities. 

The  disease  may  affect  the  superficial  or  deep  veins,  or  both,  although 
it  affects  preferably  the  large  saphenous  vein.  (Plate  XVIII.)  It  is  rarely 
spread  uniformly  throughout  the  main  trunk  and  its  finer  branches,  but 
usually  more  pronounced  in  certain  sections.  Sometimes  it  is  chiefly  the 
main  trunk  and  the  larger  branches  which  are  dilated  to  the  size  of  the 
little  finger,  forming  tortuous  bluish  cords  beneath,  or  projecting  into,  the 
skin,  particularly  in  the  calf;  sometimes  one  finds  a  dilatation  of  the  finer 
and  finest  branches  over  a  more  or  less  extensive  area,  especially  at  the 
ankle  or  on  the  dorsum  of  the  foot,  without  any  great  involvement  of 
the  larger  branches.     The  dilatation  may  be  fusiform  or  sacculated. 


> 

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VARICOSE  VEINS  OF  THE  LEG. 


091 


(Fig.  432.)  The  sluggish  circulation  or  temporary  stasis  in  these 
dilatations  conduces  to  coagulation;  the  clot  may  organize  and  the  nod- 
ules become  obliterated.  Calcium  salts  may  be  deposited  to  form  the 
so-called  phleboliths,  often  felt  in  large  numbers  under  the  skin.  Not 
infrequently  the  irritation  causes  extensive  coagulation,  starting  from  a 
single  nodule  and  extending  through  the  diseased  trunk;  large  areas 
are  thus  thrombosed;  eventually  the  entire  saphenous  vein  or  even  the 
femoral.  The  danger  of  embolism  from  loosening  of  a  thrombus  is 
self-evident.     In  the  dilated  section   the  wall    is   usually  more  or   less 

Fig.  432. 


Varicose  veins  of  lea:  with  large  varix  in  the  popliteal  space,     (v.  Bruns.) 


thickened,  but  often  very  thin   in  places,  particularly  in  the  sacculated 
or  nodular  varices;  rupture  is  therefore  frequent. 

In  the  advanced  stage  the  valves  become  more  or  less  insufficient,  by 
reason  of  which  the  insufficiency  and  the  dilatation  act  reciprocally  in 
producing  further  dilatation  of  the  vein  beyond.  The  significance  of 
this  action  is  shown  by  Trendelenburg's  test  of  elevating  the  limb  for 
a  short  time,  stroking  the  blood  centripetally,  and  compressing  the 
saphenous  trunk;  with  the  vein  still  compressed  the  patient  then  stands, 
and  the  varices  below  fill  gradually  and  only  partially  with  blood  from 
the  periphery;  on  removing  the  compression  the  blood  rushes  down  sud- 


692  DISEASES  OF  THE  LEG. 

denly  into  the  veins  and  distends  them  instantly  ad  maximum  with  all 
the  force  imparted  to  it  by  the  blood-column  extending  to  the  heart. 

Trophic  disturbances  gradually  develop  from  the  effect  of  the  retarded 
and  obstructed  venous  circulation.  The  skin  of  the  foot  and  leg,  livid 
or  bluish-red,  becomes  hard,  easily  vulnerable,  and  liable  to  inflamma- 
tion, especially  eczema;  all  lesions,  even  slight  abrasions,  heal  over  with 
difficulty  and  often  become  ulcerated.  The  ankle,  and  later  the  entire 
foot,  swells  after  standing  for  any  length  of  time,  as  the  result  of  which 
a  growth  of  new  connective  tissue  under  the  skin  produces  gradual  but 
permanent  thickening.  The  adipose  tissue  over  the  varices  disappears 
largely,  the  nodulated  veins  become  adherent  to  the  skin,  which  in  turn 
becomes  thinner  and  finally  ruptures  on  the  slightest  provocation.  The 
hemorrhage  from  such  ruptured  varices  is  easily  checked  by  pressure 
and  elevation,  but  may  otherwise  be  fatal.  The  ruptured  vein  favors 
the  formation  of  more  ulcers.  The  muscles  become  relaxed  and  atrophic, 
so  that  the  patient  is  easily  fatigued,  unable  to  walk  long  distances,  or 
even  do  work  requiring  protracted  standing;  secondarily  the  relaxation 
may  cause  flat-foot.  The  latter  and  hyperidrosis  are  very  frequent 
accompaniments  of  primary  varices.  Beside  the  muscular  weakness 
and  feeling  of  tension  in  the  leg,  the  patients  often  complain  of  pains 
either  indefinite  or  of  a  shooting  character  and  radiating  throughout  the 
leg  and  foot;  occasionally  there  is  typical  sciatic  neuralgia.  Views  differ 
as  to  whether  this  is  due  solely  to  the  pressure  of  the  smaller  dilated 
veins  upon  the  nerves  or  to  an  actual  secondary  neuritis.  The  discomfort 
varies  greatly  and  does  not  always  correspond  to  the  amount  of  visible 
dilatation.  One  sees  persons  in  whom  the  trunks  and  main  branches 
of  the  subcutaneous  veins  have  been  dilated  and  tortuous  for  years 
without  producing  any  particular  subjective  disturbance;  then  again 
others  with  very  considerable  discomfort,  but  in  whom  the  dilatation 
is  much  less  pronounced;  in  general,  extensive  involvement  of  large 
areas  of  the  finer  veins  apparently  produces  more  discomfort  than 
dilatation  confined  chiefly  to  the  larger  branches. 

Rupture  of  the  superficial  veins  has  already  been  mentioned. 
Rupture  of  the  deeper  varices  may  occur  spontaneously  or  after 
exertion  or  trauma.  In  the  author's  experience,  extending  through 
many  years,  rupture  of  the  small  veins  in  and  beneath  the  skin  is  always 
followed  by  a  macular  brownish  pigmentation  of  the  skin,  especially  of 
the  ankle.  Rupture  of  the  larger  deep  veins  causes  a  marked  intermus- 
cular and  intramuscular  infiltration  manifested  by  a  rapidly  develop- 
ing, often  extensive  and  painful  hard  swelling,  especially  in  the  calf; 
in  twenty-four  to  forty-eight  hours  ecchymosis  becomes  distinct  and 
denotes  the  character  of  the  swelling.  The  pressure  may  produce  severe 
circulatory  disturbances.  A  similar  acute  and  painful  swelling  is  caused 
by  inflammation  of  the  deep  varices,  but  the  absence  of  ecchymosis,  the 
rapid  appearance  of  inflammatory  redness,  the  fever,  although  not  always 
present  or  high,  and  the  more  cord-like  and  less  diffuse  character  of  the 
deep  swelling  after  the  acute  symptoms  have  subsided,  make  it  possible 
to  distinguish  the  two  conditions.     Inflammation  of  the  veins  is  usually 


VMIICOSE  VEINS  OF  THE  LEG.  G93 

accompanied  by  thrombosis,  and  it  is  not  always  possible  to  determine 

which  is  primary.  Although  the  inflammation  finally  disappears  in  the 
majority  of  cases,  it  may  advance  to  suppuration  of  the  thrombus,  or 
to  periphlebitis  and  phlegmon. 

The  above  are  the  essential  points  in  the  symptomatology  and  diag- 
nosis of  varicose  veins  of  the  leg.  Varices  of  the  subcutaneous  veins 
are  easily  recognized.  Those  affecting  the  deep  veins  alone  may  he 
mistaken;  but  as  a  rule  the  oedema  of  the  ankle  without  recognizable 
internal  cause,  the  dilatation  of  the  finer  veins  of  the  skin  on  the  dorsum 
of  the  foot  and  about  the  ankle,  both  increased  by  being  on  the  feet 
for  a  long  time  and  improved  by  elevating  the  limb,  make  the  diagnosis 
possible  even  after  comparatively  brief  observation. 

Treatment. — It  is  rarely  possible  to  carry  out  a  causal  therapy  against 
varicose  veins.  It  is  self-understood  that  all  factors  which  can  be 
brought  to  light  should  be  weighed  carefully  and  all  hindrances  to  the 
return  of  venous  blood  removed  as  far  as  possible.  Any  abdominal 
tumor  can  be  removed,  the  wearing  of  tight  garters  forbidden,  and  the 
bad  effects  of  protracted  standing  pointed  out,  but  on  purely  social 
grounds  the  patient  is  unable  as  a  rule  to  meet  the  latter  requirements. 
A  younger  person  is  rarely  able  to  change  his  occupation  for  one  allowing 
lighter  work  and  shorter  hours  on  his  feet.  So  the  surgeon  is  generally 
limited  to  palliative  treatment.  The  most  effectual  remedy  is  naturally 
to  elevate  the  limb,  but  this  can  only  be  carried  out  temporarily  to  over- 
come complications  or  relieve  especially  severe  discomfort.  As  long  as 
the  patient  is  about,  the  surgeon  is  limited  to  preventing  the  venous 
congestion  by  applying  uniform  compression  by  means  of  a  flannel  or 
other  bandage;  or,  better  still,  a  well-fitting  elastic  stocking.  As  the 
latter  only  retains  its  elasticity  for  a  short  time,  has  to  be  renewed,  and 
is  expensive,  it  is  often  beyond  the  means  of  the  laboring  classes,  to 
whom  it  is  most  indispensable.  Massage,  cold  baths,  followed  by  active 
rubbing  of  the  skin,  and  appropriate  exercises  to  strengthen  the  muscles, 
are  beneficial;  cycling  has  proved  of  service  in  a  few  instances;  on  the 
other  hand,  riding  increases  the  trouble.  This  is  explained  by  the  fact 
that  in  cycling  all  the  muscles  of  the  limb  are  constantly  in  motion  and 
thus  aid  the  return  of  blood,  whereas  in  riding  the  thigh  is  pressed 
firmly  against  the  saddle. 

Landerer's  pad,  fitted  with  a  water  cushion  and  having  attached  to 
it  an  elastic  metal  band  with  a  parabolic  curve  is  useful  for  compressing 
the  saphenous  vein  above  the  varices;  if  the  valves  are  insufficient  it 
can  be  applied  above  or  below  the  knee;  it  acts  the  same  as  ligation  in 
closing  the  vein,  hence,  like  the  latter,  it  is  of  value  only  when  the 
Trendelenburg  test  is  positive.  Bruck  devised  rubber  air  cushions  of 
various  sizes  and  shapes  to  be  worn  over  the  varices  to  diminish  the 
pain.  Kramer  proposed  longitudinal  incision  of  the  thrombosed  veins 
throughout  their  entire  extent  and  removal  of  the  clots  to  relieve  the 
discomfort. 

A  radical  procedure  is  the  natural  outcome  of  the  inefficacy  of  pallia- 
tive measures  to  relieve  the  often  severe  discomfort  of  this  common  and 


694  DISEASES  OF  THE  LEG. 

troublesome  affection.  The  various  methods  aiming  to  secure  recovery 
by  causing  thrombosis  or  obliteration  of  the  veins  by  the  formation  of 
adhesions,  namely,  compression,  cauterization,  electropuncture,  injec- 
tion of  alcohol  or  of  liquor  ferri  chloridi,  etc.,  in  or  about  the  veins, 
are  only  of  historic  interest,  as  they  were  all  found  ineffectual  or  dan- 
gerous. The  subcutaneous  ligation  method  of  Velpeau  and  Delpech, 
later  recommended  by  Schede,  has  been  abandoned  for  the  present 
method  of  open  ligation,  resection,  or  excision.  These  latter  methods 
are  not  new,  however,  as  Celsus  ligated  for  varicose  veins.  Their 
permanent  place  in  surgery  was  first  assured  by  Trendelenburg's  demon- 
stration of  the  effect  of  ligating  the  saphenous  vein,  by  which  he  showed 
after  ten  years'  experience  in  which  of  the  cases  success  could  be  expected, 
namely,  in  those  in  which  the  valves  are  insufficient. 

Ligation  of  the  Saphenous  Vein.— The  saphenous  vein  is  exposed 
by  a  longitudinal,  or,  better,  a  transverse  incision  at  the  junction  of 
the  upper  and  middle  third  of  the  thigh;  the  vein  is  double  ligated 
and  divided,  or,  better,  a  piece  \  to  1  inch  long  is  cut  out  between  the 
ligatures.  The  application  of  the  Esmarch  is  immaterial.  The  site  of 
incision,  however,  is  important,  as  the  mistake  is  frequently  made  of 
hunting  for  the  vein  too  close  beneath  the  surface  if  it  cannot  be  seen 
— e.g.,  in  stout  subjects;  local  cocaine  anaesthesia  is  sufficient.  Many 
surgeons  advise  ligating  the  saphenous  just  below  its  junction  with  the 
femoral  in  order  to  meet  the  possibility  of  unusually  high  branching, 
otherwise  each  branch  has  to  be  ligated  separately. 

Since  Trendelenburg's  publication  in  1S91  the  favorable  results  of  the 
operation  have  been  confirmed  by  many  authors,  and  the  intervening 
time  has  been  sufficiently  long  to  enable  one  to  judge  of  the  protection 
afforded  against  recurrence.  In  appropriate  cases  the  relief  follows 
quickly;  the  wound  heals  by  primary  intention  in  about  ten  days,  any 
existing  ulcers  heal  over  rapidly  and  permanently  if  not  too  large,  and 
provided  that  they  are  kept  clean  and  protected;  the  number  of  recur- 
rences is  small.  It  cannot  be  denied,  however,  that  the  operation  is  not 
without  its  dangers;  in  spite  of  complete  asepsis,  thrombosis  of  the  proxi- 
mal stump  and  embolism  have  occurred,  a  warning  against  operating 
without  a  strict  indication.  If  the  external  pudic  or  the  superficial 
epigastric  veins  open  into  the  saphenous,  Ledderhose  recommends  that 
they  be  ligated.  To  overcome  the  troublesome  oedema  of  the  leg,  in 
addition  to  ligating  the  saphenous  vein  he  makes  several  longitudinal 
incisions  from  the  ankle  to  the  knee,  and  with  the  limb  in  the  vertical 
position  also  others  at  the  sides  and  behind,  carrying  them  through  the 
skin  and  subcutaneous  tissue  down  to  the  fascia  of  the  muscle ;  afterward 
he  closes  them  with  continuous  sutures  and  applies  a  dressing  with 
pressure. 

Excision  of  varicose  veins  is  a  larger  operation.  Although  performed 
in  the  preantiseptic  period,  its  value  was  first  established  after  the 
introduction  of  asepsis;  recently  it  has  been  especially  recommended  by 
Madelung.  On  account  of  the  gradual  dilatation  of  the  collaterals,  the 
operation  does  not  always  prevent  recurrence,  but  may  be  successful 


ELEPHANTIASIS  OE  THE  LEG,  695 

where  the  insufficiency  of  the  valves  is  not  pronounced;  as  numerous 
communications  are  thereby  cut  off  the  danger  of  recurrence  is  slight. 
Particularly  in  tlie  eases  in  which  entire  networks  of  veins,  like  an 
angioma,  distend  the  skin  or  are  thrombosed,  the  author  usually 
excises  these  masses  in  addition  to  ligating  the  saphenous.  To  avoid 
making  one  long  incision  in  excising  the  saphenous  vein,  Casati  recom- 
mends multiple  incisions  1 V  inches  long,  the  sections  of  vein  between 
being  removed  subcutaneously;  he  does  not  ligate  the  lateral  branches. 


ELEPHANTIASIS  OF  THE  LEG. 

The  affection  known  as  elephantiasis  Arabum  may  be  regarded  as  the 
result  of  severe  circulatory  disturbances,  of  repeated  attacks  of  arterial 
hyperemia,  of  chronic  obstruction  of  the  venous  circulation,  and  espe- 
cially as  a  disease  of  the  lymphatics.  Although  met  with  everywhere, 
and  endemic  in  the  tropics,  it  is  seen  only  sporadically  in  and  about 
Germany  [and  America].  In  spite  of  its  great  scientific  interest  it  is  of 
slight  clinical  significance  on  account  of  its  infre(|uency.  It  is  essentially 
a  chronic  inflammation,  leading  to  thickening  of  the  skin  and  subcutis 
through  growth  of  connective  tissue,  and  often  causes  enormous 
increase  in  the  size  of  the  parts  involved,  chiefly  the  leg. 

Elephantiasis  begins  as  a  rule  between  the  fifteenth  and  twentieth 
years,  rarely  earlier,  and  seldom  after  the  thirtieth  year.  The  onset  is 
like  that  of  an  acute  lymphangitis,  and  in  the  endemic  form  often  attacks 
a  previously  healthy  limb;  but  in  the  sporadic  form,  as  it  occurs  chiefly 
in  Germany,  it  more  frequently  follows  long-standing  irritation,  espe- 
cially chronic  ulcers.  The  initial  chill,  fever,  and  general  malaise  are 
accompanied  by  the  appearance  of  a  hot,  tender  swelling  in  the  leg,  over 
which  the  skin  is  reddened  and  streaked  in  lines  corresponding  to  the 
lymphatics  and  usually  extending  up  to  the  knee.  The  attack  lasts  one 
to  five  days;  the  inflammatory  changes  may  subside  completely;  a  slight 
swelling  often  persists,  however,  after  the  first  attack.  The  attacks  are 
repeated  at  varying  intervals  of  weeks  or  months  with  the  same  symp- 
toms but  with  less  intensity.  The  condition  has  been  looked  upon  as 
being  an  erysipelas,  but  this  is  wrong,  although  infectious  processes 
unquestionably  play  a  certain  part  in  the  inflammatory  exacerbations. 

As  the  attacks  increase,  the  continuous  swelling  which  was  at  first 
soft  becomes  more  solid,  the  skin  becomes  thickened  and  more  firmly 
adherent  to  its  substratum,  and  can  be  pitted  in  only  a  few  places.  In  five 
to  ten  years  the  leg,  especially  the  lower  half,  becomes  greatly  enlarged, 
the  thickened  (verrucous)  skin  is  thrown  into  heavy  folds  which  hang 
down  over  the  normal  or  involved  foot  to  the  ground,  the  folds  containing 
epithelial  detritus,  sebum,  and  dirt.  (Fig.  433.)  The  epidermis  becomes 
greatly  thickened  in  the  form  of  flat  plates  or  horny  callosities,  or  it  has 
more  the  appearance  of  a  papilloma  if  the  papilla?  are  involved;  the  wart- 
like projections,  the  size  of  a  millet-seed  or  lentil  and  separated  by  deep 
furrows,  give  the  skin  the  appearance  of  a  coat  of  mail.    The  decompo- 


696 


DISEASES  OF  THE  LEG. 


sition  of  the  sweat  and  oils  from  the  skin  leads  to  the  production  of 
extensive  eczema  and  ulcers  with  a  penetrating  foul  odor.  The  muscles 
atrophy  and  the  bone  becomes  somewhat  involved  in  the  thickening. 
In  spite  of  the  muscular  weakness  and  the  impaired  mobility  of  the  ankle- 
joint  due  to  the  shapeless  swelling  of  the  foot  and  leg,  the  patient  may 
still  be  able  to  walk  for  some  time  and  to  some  distance;  occasionally 
the  functional  disturbance  is  marked  at  an  early  period. 

The  etiology  and  essential  pathogenesis  is  still  obscure  in  spite  of 
numerous  investigations.  From  Teichmann's  studies  it  is  known  at 
least  that  the  disease  is  due  to  changes  both  in  the  bloodvessels  and  in 


Fig.  433. 


Elephantiasis  of  the  1 


the  lymphatics.  The  superficial  lymph-capillaries  and  lymph-spaces 
are  much  dilated;  the  deeper  lymphatics  are  replaced  by  lymph-cells  or 
become  thrombosed  or  narrowed  even  to  obliteration  by  a  growth  of 
the  endothelium.  The  glands  are  occasionally  enlarged  and  solid,  but 
otherwise  without  intrinsic  changes. 

Prognosis. — The  prognosis  of  the  disease  is  very  unfavorable.  Although 
the  general  condition  of  the  patient  often  remains  unchanged  for  many 
years,  the  local  affection  usually  advances  slowly  but  steadily. 

Treatment. — In  recent  cases  the  limb  is  elevated,  compression  band- 
ages applied,  the  limb  massaged,  and  by  strict  cleanliness  all  inflamma- 
tory irritation  prevented.     Compression  of  the  large  arteries  with  the 


ACUTE  OSTEOMYELITIS  OF  THE  BONES  OF  THE  LEG,      097 

finger  or  tourniquet,  repeated  frequently  for  several  hours,  lias  been 
warmly  recommended.     Especially  troublesome  hypertrophied  ma 
nf  skin  have  been  excised.    Carnochan  and  others  recommend  ligation 
of  the  femoral  artery  in  severe  eases;  the  swelling  diminishes  to  some 

extent  l>ut  the  result  is  very  uncertain,  almost  always  only  temporary. 
The  operation  has  occasionally  been  followed  by  gangrene  of  the  leg, 
and  has  therefore  been  almost  entirely  abandoned. 


ACUTE  OSTEOMYELITIS  OF  THE  BONES  OF  THE  LEG. 

Acute  osteomyelitis  attacks  no  other  bone  so  frequently  as  the  tibia, 
either  alone  or  simultaneously  with  other  long  bones;  according  to 
V.  Brans,  the  tibia  was  affected  in  42  per  cent,  of  all  cases,  the  fibula 
in  only  3  per  cent.  The  favorite  site  of  the  disease  is  the  spongiosa  of 
the  shaft  between  the  epiphyseal  line  and  the  medulla,  although  it  very 
often  spreads  to  the  medulla  at  an  early  period.  The  upper  and  lower 
ends  of  the  shaft  are  not  infrequently  involved  simultaneously  or  in 
close  sequence  while  the  middle  of  the  shaft  is  left  free,  or  the  inflamma- 
tion may  extend  rapidly  through  the  entire  shaft.  The  epiphyses  are 
frequently  involved  secondarily,  rarely  primarily;  in  the  head  of  the 
tibia  particularly  the  suppuration  is  liable  to  advance  rapidly  through 
the  meshes  of  the  spongiosa  to  the  articular  cartilage. 

Symptoms. — The  clinical  picture  and  the  form  of  the  disease  vary  as 
much  as  the  site  and  distribution.  In  the  tibia  one  sees  both  the  sub- 
acute and  the  chronic  forms  of  periostitis  albuminosa  (Oilier,  Schlange, 
Garre);  the  purulent  ichorous  form,  rapidly  fatal  in  a  few  days  with 
the  symptoms  of  a  severe  general  infection;  also  sclerosing  ostitis  with 
merely  marked  thickening  of  the  bone;  and  further,  severe  suppurating 
osteomyelitis  and  periostitis  with  perforation  and  partial  or  complete 
necrosis;  all  these  forms  are  apparently  independent  of  the  nature  of 
the  bacteria.  Although  the  type  of  osteomyelitis  following  typhoid 
and  produced  by  the  typhoid  bacillus  is  as  a  rale  merely  a  circum- 
scribed focus  with  thickening  due  to  growth  of  the  periosteum  or  in 
addition  containing  a  small  abscess  with  or  without  the  formation  of  a 
small  sequestrum,  and  although  Staphylococcus  pyogenes  albus  is  more 
frequently  found  in  the  mild  cases  and  Staphylococcus  pyogenes  aureus  or 
Streptococcus  pyogenes  are  rarely  absent  in  the  severe  cases,  nevertheless 
Garre  has  found  Staphylococcus  pyogenes  aureus  in  pure  culture  in 
relatively  simple  periostitis  albuminosa,  and  vice  versa  Staphylococcus 
pyogenes  albus  has  been  found  alone  or  with  the  typhoid  bacillus  in  the 
very  severe  cases.  The  onset  is  usually  accompanied  by  severe  chills, 
high  fever,  and  severe  constitutional  disturbance.  If  the  sensorium  is 
not  immediately  dulled,  as  sometimes  happens  in  very  severe  cases,  the 
intense  pain  is  referred  to  the  seat  of  the  disease.  Even  if  the  patient  is 
in  a  condition  of  stupor,  careful  search  of  the  entire  body  for  a  point  of 
tenderness,  taken  in  connection  with  the  generally  complete  loss  of 
function  and  relaxation  of  the  affected  limb,  will  reveal  the  seat  and 


G98  DISEASES  OF  THE  LEG. 

nature  of  the  disease.  The  important  objective  symptoms,  first  of  all, 
the  swelling  corresponding  to  the  spot  of  greatest  tenderness,  appear 
early  on  account  of  the  superficial  position  of  the  tibia;  as  the  swelling 
is  due  to  subperiosteal  exudation,  it  is  firm  at  the  outset  and  feels  like  a 
protrusion  of  the  bone  itself.  According  to  its  extent,  it  is  limited  to 
part  of  the  anterior  surface  of  the  tibia  or  involves  the  entire  length  of 
the  shaft.  At  the  outset  the  overlying  soft  parts  are  sharply  defined, 
but  soon  become  infiltrated,  swollen,  oedematous,  the  skin  red  and  often 
containing  a  bluish  spot.  If  the  disease  is  limited,  the  oedema  also 
extends  only  slightly  beyond  it;  if  diffuse  or  in  the  upper  and  lower  part 
of  the  shaft,  the  oedema  may  extend  over  the  leg  and  foot  and  beyond 
the  knee.  The  subcutaneous  veins  are  often  greatly  dilated  and  visible 
through  the  tense,  glossy  skin.  At  this  stage  the  affection  could  only  be 
confused  with  severe  phlegmon,  an  error  of  slight  significance,  as  the 
necessary  incision  would  reveal  the  condition  in  either  case.  The  sub- 
periosteal abscess,  opened  by  incising,  in  the  first  few  days  usually  con- 
tains, not  pure  yellow,  but  also  bloody,  discolored  pus.  It  spreads  out 
over  a  varying  extent  of  the  smooth  surface  of  the  shaft,  occasionally 
from  one  epiphyseal  line  to  the  other. 

After  incision  or  perforation  the  fever  and  pain  generally  subside 
entirely  if  the  disease  is  in  the  form  of  a  limited  suppurative  periostitis; 
if  the  bone  is  involved  at  the  same  time,  the  fever  and  pain  disappear 
only  after  the  medulla  has  been  opened  or  the  pus  has  perforated  out- 
ward. Perforation  may  occur  at  any  point,  but  is  most  common  in 
front  and  to  the  outer  side;  gravitation  abscesses  of  any  size  in  the 
region  of  the  calf  are  not  a  frequent  occurrence. 

If  the  abscess  is  incised  early,  the  periosteum  may  grow  back  upon 
the  bone;  and  if  only  a  small  area  is  affected,  it  may  heal  without  necro- 
sis or  the  formation  of  a  sinus,  only  a  slight  thickening  of  the  periosteum 
being  left.  In  the  majority  of  cases,  however,  especially  with  diffuse 
suppuration  about  and  in  the  bone,  necrosis  cannot  be  prevented  even 
by  early  incision;  the  periosteum  becomes  readherent  in  part,  but  in 
one  or  more  places  a  discharging  fistula  is  left,  through  which  the  probe 
strikes  a  sequestrum.  The  sequestrum  may  be  small  and  superficial, 
or  be  large  at  the  end  of  the  shaft,  in  which  case  the  continuity  of  the 
shaft  is  maintained  only  by  narrow  strips  of  the  old  bone  together  with 
the  "coffin"  of  proliferated  periosteum  formed;  in  other  instances  the 
entire  shaft  is  destroyed. 

This  is  the  usual  course,  so  that  the  diagnosis  can  be  made  early, 
even  in  the  first  few  days,  without  difficulty ;  variations,  however,  are 
not  infrequent.  Occasionally  it  is  more  subacute,  with  slight,  or  at 
times  almost  no  fever.  A  moderate  and  limited  swelling  develops 
with  some  pain  and  without  severe  constitutional  disturbance;  fluctua- 
tion becomes  distinct  in  the  course  of  a  few  weeks  and  a  small  cortical 
sequestrum  is  thrown  off;  if  situated  near  the  epiphysis,  the  condition 
suggests  a  tuberculous  ostitis,  but  its  character  is  determined  eventually 
by  the  nature  of  the  pus,  the  formation  of  a  sequestrum,  and  the  rela- 
tively rapid  recovery  after  the  latter  has  been  thrown  off. 


ACUTE  OSTEOMYELITIS  OF  THE  HOSES  OF  THE  LEO.      699 

The  rare  periostitis  albuminosa  has  the  acute  onset,  the  fever,  and 
the  same  sequestrum  formation  as  the  ordinary  form,  but  progresses 
without  suppuration,  gives  a  more  or  less  serous  exudation,  and  later 
has  a  more  subacute  course,  existing  for  months  before  perforating. 
The  equally  rare  non-purulent  sclerosing  form  of  osteomyelitis  ((Jarre), 
according  to  Haaga,  has  been  seen  in  only  20  of  559  cases  of  osteomyelitis; 
it  merely  produces  thickening  of  the  hone.  \n  the  majority  of  cases  of 
this  kind  the  disease  begins  with  an  acute  onset  in  the  typical  manner, 
and  progresses  with  high  fever,  swelling  of  the  extremity,  tenderness 

Fig.  434. 


Loss  of  growth  following  osteomyelitis  of  the  tibia,  necessitating  the  removal  of  part  of  the  shaft. 

(Whitman.) 


and  swelling  of  the  bone,  and  even  marked  infiltration  of  the  soft  parts; 
but  the  stormy  symptoms  disappear  rapidly,  the  swelling  of  the  soft 
parts  subsides  slowly,  and  recovery  follows  gradually  without  perfora- 
tion. If  seen  at  a  more  advanced  stage,  it  may  suggest  chronic  inflam- 
mation, especially  syphilitic  ostitis,  but  the  acute  onset  with  high  fever, 
the  absence  of  other  signs  of  syphilis  or  tuberculosis,  and  the  relatively 
frequent  occurrence  of  typical  suppurative  osteomyelitis  previously  or 
simultaneously  in  other  bones,  distinguish  the  affection  from  the  dis- 
eases in  question.  Miiller  recently  described  as  a  rare  result  of  acute 
osteomyelitis  a  growth  of  a  series  of  hard  tumors  each  containing  a 
small  sequestrum. 


700  DISEASES  OF  THE  LEG. 

A  frequent  complication  of  acute  osteomyelitis  of  the  tibia  is  an  inflam- 
mation of  the  knee-  or  ankle-joint,  or  of  both,  as  a  rule  appearing  in  the 
eighth  to  tenth  day  of  the  disease.  The  effusion  may  be  serous,  or  in 
severe  cases  thickly  purulent  with  red  cells  and  fibrin,  but  is  usually 
seropurulent.  The  knee  is  generally  flexed  slightly  and  the  foot  held 
extended.  The  joint-affection  is  denoted  further  by  pain,  swelling, 
and  generally  by  distinct  fluctuation;  redness  of  the  skin,  although 
commonly  present,  is  usually  slight.  The  character  of  the  effusion  can 
generally  be  determined  only  by  aspiration.  The  purulent  form  is 
commonly  followed  by  some  permanent  disturbance  even  with  proper 
treatment;  the  serous  form  is  followed  by  full  recovery,  but  the  sero- 
purulent form  only  exceptionally. 

Separation  of  the  epiphysis  is  not  a  rare  occurrence  in  the  course  of 
acute  osteomyelitis  of  the  tibia  or  fibula;  recovery  may  be  by  firm,  bony 
union,  but  the  latter  may  be  absent  if  the  periosteum  is  destroyed  by 
suppuration.  The  treatment  should  aim  to  hold  the  fragments  in  good 
position. 

A  rare  form  of  bone  abscess  found  several  times  in  the  head  of  the 
tibia,  and  first  described  by  Brodie,  should  also  be  mentioned.  It  is  an 
extremely  chronic  disease,  extending  over  many  years,  which  can  only 
be  referred,  however,  to  acute  infectious  osteomyelitis.  Pathologically 
it  consists  of  an  abscess  of  the  size  of  a  hazelnut  or  walnut,  surrounded 
by  a  thick  wall  of  sclerosed  bone  lined  with  a  thin  layer  of  granulation- 
tissue  somewhat  similar  to  mucous  membrane.  The  clinical  picture 
suggests  the  above-mentioned  sclerosing  form,  namely,  the  acute  onset, 
swelling,  and  permanent  thickening  of  the  bone;  but  the  abscess  does 
not  heal.  Often  considerable  pain  persists,  disappearing  possibly  for 
periods  of  days  or  weeks,  but  always  recurring,  and  occasionally  becom- 
ing unendurable  at  night.  The  diagnosis  can  generally  be  made  only 
with  a  certain  probability  from  the  acute  onset,  the  insidious  course,  and 
the  failure  of  all,  especially  specific,  treatment.  It  can  be  made  posi- 
tively only  by  exploratory  trephining,  or  preferably  chiselling  of<  the 
bone. 

The  disturbances  in  growth  clue  to  osteomyelitis  are  of  particular 
interest.  According;  as  the  inflammation  is  situated  near  the  line  of  the 
epiphyseal  cartilage  and  irritates  it,  or  extends  into  it  and  destroys  it, 
the  bone  may  be  lengthened,  even  §  to  1}  inches,  or  shortened,  the  more 
frequent  result.  Lengthening  of  the  tibia  tends  to  produce  a  flat-foot 
position  (eversion),  shortening  a  club-foot  position  (inversion)  of  the 
foot.  The  normal  fibula  thus  becomes  somewhat  curved  and  partially 
dislocated  at  the  tibiofibular  joints;  if  the  growth  of  the  tibia  is  arrested, 
the  head  of  the  fibula  is  gradually  displaced  upward  and  projects  at 
the  outer  side  of  the  knee-joint. 

Treatment. — The  insidious,  occasionally  severe  course  of  acute  sup- 
purative osteomyelitis  calls  for  energetic  treatment.  The  old  teaching 
to  await  the  formation  of  the  abscess  and  simply  open  it,  is  being  more 
and  more  abandoned  for  that  of  early  free  incision  and  evacuation. 
Too  much,  however,  cannot  be  expected  of  early  radical  operation,  as 


ACUTE  OSTEOMYELITIS  OF  THE  BONES  OF  THE  LEG.      7Q1 

severe  general  infection  only  too  often  complicates  the  condition  so 
early  thai  operation  cannol  prevenl  fatal  septicaemia.  Nevertheless  it  is 
sometimes  possible  to  check  the  process  or  prevent  or  limit  necrosis. 
The  superficial  position  of  the  tibia  facilitates  early  operation.  Under 
application  of  the  Esmarch  a  longitudinal  incision  is  made  over  the 
front  of  the  tibia,  the  periosteum  is  peeled  off  with  an  elevator  and  with 
a  curved  chisel  the  entire  area  of  infiltration  is  exposed  and  all  diseased 
bone  scraped  and  chiselled  out.  Foci  in  the  epiphyses  should  be 
scraped  out  carefully  to  prevenl  secondary  infection  of  the  joint;  the 
cartilage  should  be  saved  as  much  as  possible.  The  wound  is  packed 
with  iodoform  gauze,  covered  with  a  large  dressing,  and  the  limb  ele- 
vated in  a  Volkmann  splint.  The  operation  should  be  thorough  but  as 
rapid  and  limited  as  possible,  in  view  of  the  weakness  of  the  patient  due 
to  severe  constitutional  disturbance. 

If  first  seen  after  the  abscess  has  formed  and  after  the  severe  constitu- 
tional symptoms  have  subsided,  or  if  the  process  is  more  subacute,  it  is 
better  merely  to  open  the  abscess  freely  and  await  the  separation  of  the 
sequestrum  and  the  formation  of  the  "coffin."  Involvement  of  the 
knee-  or  ankle-joint  requires  aspiration  and  irrigation  with  3  per  cent, 
carbolic  solution  or  eventually  free  incision  and  drainage.  The  sclero- 
sing form  does  not  require  operation,  but  merely  rest,  elevation,  and 
warm  baths,  especially  hot  compresses  to  aid  resorption.  If  the  pain 
continues  or  shows  frequent  exacerbations,  the  bone  should  be  incised 
and  the  spongiosa,  usually  filled  with  grayish-red  or  yellowish  granu- 
lations, scraped  out;  the  same  rule  applies  to  abscess  of  the  bone.  The 
formation  of  the  sequestrum  in  the  bones  of  the  leg  in  the  event  of 
spontaneous  recovery  or  after  early  or  late  incision  does  not  differ 
essentially  from  the  usual  process  elsewhere. 

The  growth  of  periosteum,  the  so-called  "coffin"  (Todtenlade),  and 
the  consequent  thickening  of  the  bone,  is  of  practical  importance,  as  its 
limits  correspond  very  closely  to  the  extent  of  necrosis,  so  that  by  inspec- 
tion and  palpation  of  the  surface  of  the  tibia  or  fibula  one  may  estimate 
approximately  the  amount  of  exposure  necessary.  If  delay  is  war- 
ranted by  the  general  condition,  the  fever,  and  suppuration,  one  should 
wait  until  the  sequestrum  is  completely  separated  and  the  periosteum 
has  formed  a  sufficiently  solid  "coffin."  On  this  surgeons  are  almost 
all  agreed,  dishing  recommends  removal  of  the  sequestrum  before 
this  growth  is  complete;  on  incising  the  periosteum  at  this  stage  a  dis- 
tinct grating  is  felt  under  the  knife,  while  macroscopically  there  is  no 
evidence  of  bone  formation. 

As  to  the  best  method  of  sequestrotomy  the  views  are  still  divided. 
The  older  method,  which  still  has  many  distinguished  advocates,  such 
as  Konig,  merely  splits  the  sinus,  widens  the  opening  into  the  bone, 
removes  the  sequestrum  as  a  whole  or  in  pieces,  and  scrapes  out  the 
cavity.  It  has  the  advantage  of  preserving  the  new  shell  of  bone  in  its 
entire  extent  and  therefore  of  weakening  the  limb  as  little  as  possible, 
and  of  avoiding  injury  of  the  areas  of  delicate  cicatricial  tissue  adher- 
ent to  the  bone.     Its  great  disadvantage  is  that  it  prevents  thorough 


702 


DISEASES  OF  THE  LEG. 


inspection  and  removal  of  all  diseased  bone,  so  that  infiltrated  spots 
or  even  small  sequestra  are  easily  overlooked  and  form  the  basis  of 
fresh  and  often  long-continued  suppuration  and  recurrence. 

Modern  methods   aim   to   expose   the   entire   affected   area  through 
an    appropriately   long   incision.     Sinuses   are   split   or   excised.     The 
bone  is  chiselled  away  till  the  limits  of  the  process  are  well  exposed, 
and  the  sequestrum  and  all  granulations  are  then 
Fig.  435.  removed  with  the  chisel   and    sharp   spoon.     The 

.  ji  continuity  of  the  bone  should  never  be  entirely 
destroyed  if  possible;  if  the  sinuses  are  numerous 
and  scattered,  it  may  be  impossible  to  avoid  remov- 
ing all  but  a  small  bridge  of  bone.  Where  the 
suppuration  extends  high  up  into  the  head  of  the 
tibia  the  joint  should  be  carefully  avoided.  The 
cavity  is  packed.  To  shorten  the  period  of  re- 
covery and  to  improve  the  general  character  of 
the  resulting  wound,  v.  Esmarch  cut  down  the 
edges  of  the  cavity  and  in  it  implanted  the  soft  parts 
from  both  sides,  holding  them  in  position  by  sutures 
and  pressure.  Neuber  nailed  the  flaps  to  the  walls 
of  the  cavity.  Schede  blood-clots  the  cavity  ;  this 
method  has  not  fulfilled  the  former  expectation 
held  in  regard  to  it,  as  even  with  the  greatest  care 
complete  asepsis  is  rare.  Senn,  Kummell,  Drees- 
mann,  Sonnenburg,  Mayer,  Stenson,  Heintze,  and 
others  have  recommended  implantation  of  decal- 
cified bone,  plaster,  cement,  copper  amalgam,  in  the 
same  way  that  a  tooth  is  filled,  but  so  far  the  pro- 
cedures have  met  with  little  success.  Liicke  and 
Ollier's  osteoplastic  methods  are  better;  they  con- 
sist essentially  in  making  a  long  quadrilateral  flap 
of  skin,  periosteum,  and  bone,  which  is  chiselled 
off,  turned  back,  and  after  the  cavity  has  been 
cleaned,  implanted  in  it.  Bier's  method  (Fig. 
435),  especially  adapted  to  the  tibia,  differs  from 
Liicke's  only  in  that  the  flap  is  sutured  back  in 
place  instead  of  being  implanted  in  the  cavity, 
thus  giving  a  better  appearance,  although  the 
principle  of  Liicke's  method  appears  to  the  author  to  be  more  nearly 
correct. 

[At  the  International  Medical  Congress  held  in  Madrid,  in  April, 
1903,  Silbermark1  explained  that  the  failure  of  the  various  methods  of 
plugging  bone  cavities  was  due  to  the  fact  that  the  materials  used  thus 
far  had  acted  as  foreign  bodies  and  been  cast  off  with  profuse  suppura- 
tion, v.  Mosetig,  however,  had  found  a  substance  which  did  not  act 
as  a  foreign  body  and  was  completely  absorbed  and  replaced  by  granu- 


Osteoplastic  necrotomy 
of  the  tibia.    (Bier.) 


[!  Munch,  med.  Wochenschrift,  1903,  No.  20.] 


TUBERCULOSIS  OF  THE  BOSKS  OF  THE  LEG.  703 

lations  until  the  cavity  was  entirely  filled  with  new  hone,  it  being  possible 
to  study  the  concentric  diminution  of  the  cavity  with  the  ./-raw  Silber- 
mark  reported  121  cases  with  44")  cavities  which  hud  been  treated  suc- 
cessfully by  v.  Mosetig.  He  also  mentioned  an  electrical  instrument 
which  he  had  made  to  lighten  the  task  of  cleaning  out  the  cavity. 

The  method,  as  reported  by  v.  Mosetig,  before  the  Gesellschaft  fur 
Aer/te,  in  Vienna,  in  January  of  the  same  year,1  and  which  he  had  used 
during  the  previous  three  years  in  over  100  cases  of  caries  and  necrosis, 
was  as  follows:  Under  application  of  the  Esmarch  and  with  strict  anti- 
sepsis, the  periosteum  was  lifted  off  and  all  diseased  tissue  removed 
thoroughly  with  sharp  spoon,  saw,  chisel,  etc.,  until  positive  that  the 
cavity  was  aseptic.  The  result  depended  upon  the  latter  condition  and 
the  sterility  of  the  filling.  The  filling  consists  of  iodoform,  00.0;  sperma- 
ceti and  oleum  sesami,  aa  40.0;  heated  slowly  to  100°  C.  in  a  flask  on 
a  water-bath;  kept  at  this  temperature  for  fifteen  minutes;  then  removed 
and  allowed  to  cool  and  solidify,  while  shaking  constantly.  Before 
using,  it  is  melted  and  heated  to  50°  C.  in  a  thermostat.  After  the  cavity 
has  been  cleansed  of  all  diseased  tissue,  it  is  washed  out  thoroughly  with 
a  1  per  cent,  solution  of  formalin,  dried  out  with  swabs  and  then  with 
hot  air  and  filled  with  the  melted  mixture.  The  periosteum  and  skin 
are  then  sutured  without  drainage  and  a  dressing  applied.  In  fourteen 
days,  in  the  case  of  knee  resection  in  twenty-one  days,  the  dressing  is 
changed  and  the  skin  sutures  removed.  The  course  is  almost  afebrile 
and  there  is  never  iodoform  intoxication.  The  hardened  filling  is  grad- 
ually replaced  by  granulations  and  new  bone,  as  demonstrated  by  the 
a;-ray  (Holzknecht).    The  patient  can  be  about. 

The  size  of  the  cavity,  according  to  Silbermark,  is  no  contraindication; 
in  some  instances  two-thirds  of  the  shaft  having  been  removed  and 
replaced  by  the  filling.  The  same  author2  emphasizes  the  importance 
of  absolutely  checking  all  bleeding  and  drying  out  the  cavity  with  hot 
air,  and  describes  the  electrical  hot-air  apparatus  used  in  v.  Mosetig's 
clinic.3  To  check  the  oozing  of  blood  even  more  surely,  Damianos4 
swabs  out  the  cavity  with  adrenalin  pledgets  after  thorough  cleansing 
and  drying  with  hot  air.  He  cites  150  cases  treated  successfully,  and 
attributes  the  results  to  extreme  care  in  the  technic  and  in  determining 
the  time  of  operation.  According  to  Damianos,  v.  Mosetig  prefers  a 
flap  section  to  direct  incision.  In  chronic  osteomyelitis  the  cavity  can 
be  plugged  at  once,  but  in  acute  cases  not  until  several  weeks  after  the 
onset.] 

TUBERCULOSIS  OF  THE  BONES  OF  THE  LEG. 

Tuberculous  foci,  "granulation"  foci,  and  sequestra  are  found  rather 
frequently  in  the  epiphyses  of  the  bones  of  the  leg.  They  often  give 
rise  to  secondary  tuberculosis  of  the  knee  or  ankle.     The  head  of  the 

[!   Munch,  med.  Wochenschrift,  1903,  No.  2.  -   Zentralblatt  f.  Chirurgie,  1903,  No.  25. 

3  Deutsche  Zeitschrift  f.  Chirurgie,  Band  lxvi.  p.  589. 
*  Zentralblatt  f.  Chirurgie,  1904,  No.  6.] 


704 


DISEASES  OF  THE  LEG. 


Fig.  436. 


tibia  is  the  seat  of  choice.  Moderate,  dull  pain,  continuing  for  weeks 
or  months,  increased  by  pressure  and  associated  with  a  flat  thickening 
of  the  head  of  the  tibia  near  the  spine  which  develops  gradually  and 
points  clearly  to  growth  of  the  periosteum,  should  always  awaken  sus- 
picion of  a  tuberculous  focus  in  the  bone,  especially  if  the  patient  gives 
evidence  of  tuberculosis  elsewhere  or  a  history  of  tuberculous  heredity. 
The  diagnosis  is  positive  as  soon  as  a  cold  abscess  forms.  This  is  often 
the  first  symptom;  at  least  the  changes  may  be  so  slight  as  to  have 
been  previously  unnoticed  by  the  patient  or  relatives.  The  knee-joint 
may  be  uninvolved.  It  is  important  to  recognize  the  condition  at  this 
stage,  as  by  timely  evacuation  of  the  focus  perforation  into  the  knee  can 
be  prevented.  The  same  applies  to  foci  in  the  lower  epiphysis.  Tuber- 
culosis is  not  infrequently  confused  with 
acute  or  subacute  osteomyelitis  of  the 
epiphysis,  but  the  acute  onset  of  the  latter 
with  high  fever,  severe  pain,  and  the  ab- 
sence of  symptoms  of  tuberculosis  else- 
where, the  character  of  the  pus  and  the 
granulations  of  the  sinus,  all  point  to  an 
osteomyelitic  process.  After  all,  an  error 
is  not  serious  clinically  as  the  treatment 
is  the  same  in  both  cases. 

The  reverse  process,  namely,  secondary 
involvement  of  the  epiphysis  from  a  pri- 
mary tuberculosis  of  the  knee  or  ankle,  is 
also  often  seen.  Tuberculosis  of  the  shaft 
is  much  less  common  and  less  known,  and 
is  divisible  into  three  groups:  1.  By  trans- 
mission from  a  process  in  the  joint  or 
epiphysis.  2.  Primary  of  the  spongiosa, 
with  or  without  an  independent  process  in 
the  epiphysis,  in  the  form  of  (a)  a  granu- 
lation focus,  (b)  sequestrum,  or  (c)  pro- 
gressive infiltrating  caseation.  3.  Primary 
tuberculous  osteomyelitis:  (a) circumscribed 
foci,  (b)  involving  the  entire  medulla  and 
generally  leading  to  partial  sequestration. 
(Fig.  436.)  Anatomically  and  clinically  the 
process  is  quite  analogous  to  that  in  the 
epiphysis  or  in  the  spongiosa;  but  on  ac- 
count of  its  rarity  one  does  not  always 
think  immediately  of  tuberculosis.  Although  in  comparison  to  acute 
osteomyelitis  the  course  is  usually  more  insidious  and  chronic,  the  onset 
is  occasionally  rather  acute  and  the  course  more  subacute.  In  this  case 
the  diagnosis  may  be  first  made  at  the  operation  by  the  thin,  cheesy,  or 
crumbling  pus,  the  grayish-red  pyogenic  membrane  studded  with  tuber- 
cles lining  the  abscess  cavity,  the  scattered,  cheesy  granulations,  and 
the  grayish-yellow  porous  sequestrum  partly  honeycombed  with  granu- 


Tuberculous  osteomyelitis  of  the 
of  the  tibia. 


SYPHILIS  OF  THE  BOXES  OF  THE  LEG.  705 

lations.     The   author  has  seen   this  rare  affection  chiefly  in  children, 
especially  those  with  multiple  foci  of  tuberculosis. 

Treatment. — Unless  the  poor  general  condition  and  an  extension  of 
the  local  process  demand  amputation  of  the  limb,  the  treatment  is  con- 
fined to  tree  exposure  and  thorough  removal  of  the  focus. 


SYPHILIS  OF  THE  BONES  OF  THE  LEG. 

Acquired  syphilis  appears  in  various  forms  in  its  seat  of  choice  in 
the  bones,  the  tibia;  it  is  less  frequent,  although  not  rare,  in  the  fibula. 
Syphilitic  periostitis  is  the  form  most  generally  known,  leading  to  the 
production  at  one  or  more  spots  of  flat,  firm,  later  more  rounded 
gummata,  soft  in  the  middle,  and  finely  pseudofluctuating;  the  bone 
becomes  irregularly  absorbed  and  exostoses  grow  out  around  it;  the 
tumor  becomes  adherent  to  the  skin,  perforates,  and  gives  a  characteristic 
sharply  defined  crater-like  specific  ulcer  with  a  greasy  membrane;  after 
the  process  heals,  the  surface  of  the  bone  remains  very  irregular,  the 
cicatricial  scars  of  the  skin  being  adherent  to  the  deep  depressions  in 
the  bone.  Particularly  the  spine  of  the  tibia  loses  its  sharp  outline; 
long  after  recovery  one  can  make  a  probable  diagnosis  of  syphilis  from 
the  changed  form  of  the  bone. 

Gummatous  osteomyelitis  of  the  tibia  is  not  less  frequent,  possibly 
more  so;  some  syphilographers,  like  Gangolphe,  assume  at  least  that  it 
is  always  associated  with  syphilitic  periostitis.  The  gumma  may  develop 
in  the  spongiosa  or  the  medulla  as  a  circumscribed  tumor  or  it  may 
spread  diffusely.  Like  all  granulation-tissue,  it  absorbs  the  bone,  but 
irritates  the  periosteum  to  the  formation  of  a  thick  circumscribed  or 
diffuse  periostosis  or  hyperostosis.  Spontaneous  fracture  may  occur  if 
proliferation  does  not  keep  pace  with  absorption  of  the  bone. 

Syphilis  of  the  bone  may  give  no  symptoms  for  a  long  while.  Usually 
the  patient  complains  of  a  long-standing  dull,  aching  pain,  with  periods 
of  diminution  and  exacerbation,  the  latter  especially  at  night  (dolores 
osteocopi).  This  in  connection  with  a  palpable  thickening  of  the  bone 
usually  leads  to  the  proper  diagnosis  as  soon  as  a  history  of  syphilis  is 
obtained.  In  the  absence  of  such  a  history  the  surgeon  thinks  of  subacute 
osteomyelitis,  abscess  of  the  bone,  tuberculosis,  and  especially  periosteal 
or  myeloid  tumors.  But  osteomyelitis  begins  more  violently:  with 
abscess  of  the  bone  there  is  usually  a  history  of  previous  osteomyelitis; 
malignant  neoplasms  generally  grow  more  rapidly  and  are  more  sharply 
defined.  Nevertheless  in  individual  cases  the  diagnosis  is  often  difficult. 
In  doubtful  cases  specific  treatment  should  always  be  tried  first.  Gum- 
mata react  rather  promptly  to  large  doses  of  potassium  iodide;  the  pain 
diminishes  but  the  thickening  of  the  bone  persists  except  in  as  far  as 
it  is  due  to  periosteal  gummatous  nodules. 

Congenital  syphilis  sometimes  comes  to  light  in  the  form  of  an  osteo- 
chondritis; it  is  seen  rather  frequently  in  the  upper  epiphysis  of  the  tibia 
(Wegner),  with  shortening  or  lengthening  of  the  bone  according  as  the 
Vol.  ILL— 45 


706 


DISEASES  OF  THE  LEO. 


epiphyseal  line  is  destroyed  or  merely  irritated.  A  second  form  is  the 
ossifying  periostitis;  gummata  are  rare.  The  inflammation  of  the  skin 
and  bone  leads  gradually  to  the  formation  of  a  diffuse,  less  frequently 
circumscribed,  thickening  of  the  bone.  The  growth  of  periosteum  is  at 
first  moderately  firm  with  softer  spots,  but  gradually  becomes  bony 
hard.  The  growth  is  accompanied  by  moderate  pain  varying  in  intensity. 
The  hyperostosis  is  not  a  uniform  growth  and  frequently  gives  an 
increased  forward  convexity  to  the  shaft;  in  other  cases  it  produces 
lateral  flattening,  sabre-sheath  form,  as  in  rhachitis.  A  certain  amount 
of  lengthening  usually  takes  place  in  the  bone  at  the  same  time  and  with 
the  same  result  as  produced  by  lengthening  of  the  tibia  due  to  osteo- 
myelitis, namely,  development  of  an  anomalous  position  of  the  foot  and 
knee,  flat-foot  and  genu  valgum. 

The  treatment  of  syphilis  of  the  bones  does  not  differ  from  the  usual 
specific  measures. 


RHACHITIC  CURVATURES  OF  THE  LEG. 


Fig.  437. 


Rhachitis  produces  changes  in  the  bones  of  the  leg  as  severe  as  they 
are  frequent.  While  thickening,  occasionally  infraction,  of  the  epiphyseal 
cartilage  is  seen  chiefly  in  the  first  year,  the  deformities  due  to  muscular 

traction  and  encumbrance  when  the 
child  begins  to  walk  are  most  frequent 
in  the  first  to  the  fifth  year.  After  the 
sixth  year  the  number  of  cases  of  cur- 
vature diminishes  considerably  from  the 
fact  that  in  a  large  number  of  instances 
recovery  takes  place  as  the  result  of 
growth.  The  deflexions  of  the  upper 
epiphyseal  end  of  the  tibia  were  discussed 
under  genu  valgum  and  genu  varum. 

Farther  down  in  the  leg  the  site,  direc- 
tion, and  degree  of  curvature  vary 
greatly.  Only  the  principal  varieties  will 
be  discussed.  One  of  the  most  common 
is  the  outward  curvature  of  the  entire 
limb,  the  well-known  "bow-leg."  The 
curvature  may  be  unilateral  or  bilateral, 
or  one  leg  bowed  out  and  the  other  bowed 
in  (" knock-knee").  Often  in  connection 
with  bow-leg  the  lower  third  or  fourth 
of  the  leg  may  be  inflexed  and  rotated 
backward  and  inward,  the  angular  prom- 
inence facing  forward,  the  toes  turned  inward  (anterior  bow-leg,  Fig.  437). 
If  the  deformity  is  severe,  the  foot  is  usually  held  everted  in  the  valgus 
position,  otherwise  the  child  would  walk  only  on  the  outer  edge  of  the 
foot,  although  it  not  infrequently  happens  that  the  foot  turns  in  in 


Anterior  bow-leg.      (Reiner.) 


X 
X 

< 


nuAcmric  crnvArriiEs  of  the  lec. 


707 


walking.  Inflexion,  convex  forward,  at  the  junction  of  the  lower  and 
third  fourth  of  the  leg,  is  quite  characteristic  and  very  disfiguring;  the 
lower  end  of  the  leg  may  form  a  right  or  even  acute  angle  with  the 
shaft;  the  curvature  is  usually  combined  with  lateral  flattening,  sabre- 
sheath  form;  the  anteroposterior  diameter  of  the  bone  is  increased  at 
the  angle;  the  feet  are  held  slightly  Hexed  and  are  greatly  flattened. 

It  is  in  the  very  severe  eases  of  rhachitis  that  one  frequently  sees 
curvatures  in  the  middle  and  lower  third  convex  backward  and  inward. 

On  account  of  the  weakness  of  the  bones  and  the  painfulness  of 
efforts  to  walk,  rhachitic  children  often  do  not  learn  to  walk  until  the 


Fig.  438. 
a 


(a)  Rhachitic  bow-legs  in  a  three-year-old  child,     (b)  The  same  two  years  later. 
Height  42  inches.     (Veit.) 


fourth  or  even  fifth  year.  After  the  bone  has  become  hard  they  can 
walk  fairly  well,  but  the  gait  is  always  clumsy  and  waddling  on  account 
of  the  curvature  and  the  position  of  the  foot. 

The  course  of  the  affection  depends,  aside  from  the  degree  of  deformity 
and  the  time  at  which  the  disease  itself  disappears,  essentially  upon  the 
growth  of  the  bones.  If  growth  progresses  in  a  normal  manner,  the 
curvature  may  decrease  or  even  disappear  without  treatment,  as  Schlange 
and  Veit,  and  Kamps  have  demonstrated  very  clearly,  and  as  the  laity 
have  known  for  a  long  while.  (Figs.  438  and  439.)  This  is  especially 
true  of  the  cases  of  genu  valgum  or  varum  due  to  curvature  of  the 
upper  epiphysis.  If  growth  is  retarded,  which  is  always  the  case  if  the 
disease  is  severe  and  protracted,  the  deformity  persists  accordingly. 


708 


DISEASES  OF  THE  LEG. 


Wit  found  that  the  improvement  due  to  growth  alone  ended  generally 
by  the  sixth  year,  although  slight  improvement  could  be  expected  tiil 
the  tenth  year. 

Treatment. — In  the  first  two  years  the  treatment  is  generally  of  the 
rhachitis  itself  and  of  the  condition  of  the  body,  prohibiting  injudicious 
walking  while  the  disease  is  active.  Orthopaedic  treatment  is  hardly 
necessary  till  the  fifth  year.  If  the  bones  are  markedly  curved  but 
soft,  they  can  be  straightened  by  hand  and  held  by  means  of  liffht 
splints.  The  demands  of  the  parents  often  compel  one,  without  having 
any  definite  provocation,  to  straighten  the  limbs  by  means  of  orthopaedic 
apparatus.     Such  apparatus,  however,  have  to  fit  accurately  and   must 


Fig.  440. 


^  M   i       ^ 


(a)  Rhachitic  bow-leg  and  knock-knee  in  a  three-year-old  girl.     Height  41 54  inches.      (6)  Same 
two  years  later.      Height  44  inches.     (Veit.) 


be  watched  carefully  to  prevent  decubitus  or  improper  action;  further, 
they  are  cumbersome,  prevent  free  use  of  the  muscles,  and  are  little 
adapted  for  service  among  poor  people,  the  class  among  whom  the 
severest  forms  occur  most  frequently. 

Surgical  treatment  is  necessary  if  the  curvature,  and  especially  the 
functional  disturbance,  persists  after  the  fifth  or  sixth  year.  The  disad- 
vantages of  the  orthopaedic  apparatus  mentioned  make  rapid  correction 
preferable;  as  the  bones  are  usually  thick  and  solid  after  the  disease 
has  disappeared,  manual  strength  alone  is  generally  ineffectual.  In 
France  and  Italy  improved  osteoclasts  have  been  much  used  recently; 
in  Germany  osteotomy  is  preferred,  as  it  is  practically  harmless  and 


TUMORS  OF  THE  LEG.  70<j 

easily  performed  on  the  hones  of  the  leg.  To  avoid  producing  any 
shortening,  one  should  be  satisfied  with  linear  osteotomy  if  possible; 
a  small  wedge  with  base  corresponding  to  the  convexity  of  the  curvature 

can  be  excised  in  severe  cases.  Man_\  surgeons  prefer  to  chisel  through 
the  tibia  alone  and  break  the  fibula  by  hand  afterward;  the  author 
prefers  to  divide  the  fibula  first  and  the  tibia  afterward.  Rather  than 
sacrifice  too  much  hone,  it  is  better  to  divide  the  tendo  Achillis  if 
necessary.  If  division  at  more  than  one  point  is  required,  it  is  better 
to  operate  in  several  sittings. 


TUMORS  OF  THE  LEG. 

Tumors  of  the  Soft  Parts.— Carcinoma  of  the  skin  is  about  the  only 
tumor  of  the  soft  parts  requiring  special  mention.  Formerly  its  occur- 
rence was  flatly  denied,  but  in  the  last  decade  it  has  not  infrequently 
been  demonstrated  starting  from  old  ulcers;  it  is  almost  always  in  the 
form  of  a  slow-growing  pavement-epithelium  carcinoma.     The  meta- 

Fig.  442. 


Exostosis  of  the  head  of  the  fibula,     (v.  Brans.) 


morphosis  from  a  benign  ulcer  to  a  carcinoma  takes  place  gradually 
and  may  escape  attention  for  a  long  time.  The  course  is  the  only 
characteristic  point  if  the  development  of  a  tumor  does  not  of  itself 
make  the  diagnosis  clear:  a  simple  ulcer  under  proper  treatment,  namely, 
elevation  of  the  limb  and  cleanliness,  soon  takes  on  a  better  appearance, 
becomes  clean,  and  gradually  skins  over;  in  the  case  of  carcinoma  the 
putrefaction  may  be  checked  by  the  same  treatment  and  partial  cica- 


■10 


DISEASES  OF  THE  LEG. 


trization  may  occur,  but  the  disintegration  advances  steadily.  In  addi- 
tion, the  irregular,  thick,  nodular  infiltration  of  the  walls  progresses  in 
spite  of  elevation  and  rest,  and  the  granulations  become  exuberant  and 
wart-like  (cauliflower-form).  The  growth  spreads  into  the  bone  as  well 
as  superficially,  forming  a  deep  crater-like  ulcer. 

The  prognosis,  according  to  R.  Volkmann,  is  relatively  good,  as  the 
growth  is  slow,  the  tendency  to  metastasis  slight,  and  after  amputation 
of  the  limb  recurrence  occurs  in  only  about  one-half  the  cases.    Small 

tumors  may  possibly  permit  of 
Fig.  443.  simple  excision.      It    is   usually 

better,  however,  to  amputate  im- 
mediately. 

Melanotic  carcinoma  and  sar- 
coma, which  occasionally  de- 
velop from  an  apparently  harm- 
less wart  or  pigmented  nsevus, 
and  spindle-cell  and  round-cell 
sarcoma,  which  start  in  the  inter- 
muscular fascia,  are  far  more 
malignant,  but  are  fortunately 
rare. 

Of  the  benign  tumors  may  be 
mentioned  the  rheumatic  in- 
durations, dense  bands  or  nod- 
ules of  connective  tissue,  found 
especially  in  the  muscles  of  the 
calf,  and  the  rare  neoplasms, 
fibroma,  lipoma,  and  angioma. 
Tumors  of  the  Bones. — Osse- 
ous tumors  are  far  more  frequent 
and  important.  Exostoses,  the 
most  frequent  benign  form  of 
bony  growth,  are  seen  chiefly  on 
the  inner  side  of  the  upper  end 
of  the  tibia,  less  often  on  the 
fibula.  (Fig.  442.)  They  are 
sometimes  bilateral,  or  several 
are  found  together  and  are  at- 
tached to  the  bone  by  a  more 
or  less  broad  base;  in  rare  in- 
stances the  tumor  projects  like 
a  thorn  into  the  soft  parts  and 
even  pushes  the  skin  before  it.  After  reaching  a  certain  size  it  generally 
remains  stationary,  and  therefore  often  requires  no  treatment.  Or  the 
skin  over  it  may  be  rubbed  constantly  by  the  clothing  and  easily  injured; 
or  a  bursa  may  form  over  it  and  become  inflamed;  exceptionally  the 
growth  attains  considerable  size  and  has  to  be  removed  at  its  base. 
Enchondroma  is  rare  (Figs.  443  and  444);    its  favorite  site  is  the 


Enchondroma  of  the  tibia,     (v.  Bruns.) 


TUMORS  OF  Till-:  LEG. 


711 


upper  epiphyseal  line  of  the  tibia;  it  is  usually  of  congenital  origin. 
Pure  fibroma  is  also  a  rarity. 

Sarcoma  is  of  greal  practical  interest.  The  tibia  is  the  favorite  seat 
of  osseous  sarcomata,  namely,  the  periosteal  form,  which  starts  prefer- 
ably from  the  shaft,  as  well  as  the  myeloid  variety,  which  develops  in  the 
head  of  the  tibia.  Periosteal  sarcoma  is  usually  a  spindle-cell  or  round- 
cell  tumor  growing  rapidly  to  enormous  size  with  early  involvement  of 
the  muscles.  All  authors  agree  on  the  difficulty  of  early  diagnosis  before 
the  tumors  have  attained  any  size.  Differentially  chronic  osteomyelitis 
and  syphilis  are  the  principal  conditions  to  be  considered. 

Fig.  444. 


J 


Enchondroma  of  the  tibia.     Specimen  of  Fig.  443. 


Periosteal  sarcoma  seldom  projects  so  distinctly  fom  the  bone  that  it 
can  be  differentiated  from  the  above-mentioned  inflammations;  more 
frequently  the  neoplasm  spreads  underneath  the  periosteum  along  the 
entire  shaft,  although  it  is  apt  to  project  more  on  one  side  than  on  the 
others.  Amputation  of  the  thigh  is  the  only  treatment  to  be  considered; 
if  the  tumor  is  very  small  and  situated  on  the  lower  end  of  the  tibia 
or  fibula,  the  leg  may  be  amputated,  possibly  at  or  below  the  knee. 


712  DISEASES  OF  THE  LEG. 

Myeloid  sarcomata  are  generally  found  in  the  epiphysis  and  are 
usually  less  malignant.  All  the  varieties  of  myeloid  sarcoma  are  seen  in 
the  leg,  from  relatively  benign  slow-growing  giant-cell  sarcoma,  which  is 
by  far  the  most  frequent,  to  the  very  malignant  soft  myeloid  round-cell 
sarcoma.  The  overlying  periosteum  keeps  pace  fairly  well  in  growth 
with  the  absorption  of  the  bone  by  the  tumor  within  so  that  the  con- 
tinuity is  preserved.  Exceptionally  fracture  occurs.  Later  in  the 
process  the  new  sheath  of  bone  may  be  perforated  in  places  by  the  tumor. 
The  relative  benignancy  of  giant-cell  sarcoma  is  evident  from  the  fact 
that  extirpation,  as  a  rule  by  resecting  the  bone  or  by  thoroughly 
scraping  out  the  growth,  is  not  followed  by  recurrence.  As  the  tumor  is 
most  apt  to  be  situated  near  the  knee  or  ankle,  it  is  hardly  possible 
to  distinguish  it  in  the  early  stages  from  chronic  inflammation  of  the 
joint,  especially  tuberculosis.  Mistakes  of  this  sort  have  been  made  by 
the  most  experienced  surgeons. 

The  so-called  bone  aneurisms,  namely,  pulsating  bony  tumors  seen 
chiefly  in  the  upper  end  of  the  tibia,  belong  among  the  myeloid  sarco- 
mata. Although  tumor-tissue  has  not  been  found  microscopically  in 
some  of  the  cases,  and  in  spite  of  the  fact  that  in  others  ligation  of  the 
femoral  artery  has  produced  apparent  recovery,  nevertheless  tissues  with 
the  structure  of  a  sarcoma  have  been  repeatedly  found  in  the  walls  of 
these  growths;  seven  and  one-half  years  after  the  femoral  had  been 
ligated  with  apparent  success  in  one  such  case,  Dupuytren  demon- 
strated a  recurrence  that  proved  to  be  a  typical  cystic  and  softened 
sarcoma. 

The  treatment  of  these  pulsating  tumors  of  the  bone  is  the  same  as 
that  of  myeloid  sarcoma,  namely,  excision  if  the  neoplasm  is  localized 
and  slow-growing,  amputation  if  rapidly  growing. 

Carcinoma  only  occurs  in  the  bone  by  metastasis.  Of  other  tumors 
should  be  mentioned  echinococcus  cysts,  especially  those  in  the  tibia; 
unlike  true  neoplasms  they  develop  in  the  medulla  without  exciting 
any  very  great  proliferation  of  the  periosteum ;  as  a  rule  the  bone  is  not 
enlarged.  The  cyst  may  exist  for  a  long  time  without  giving  any  symp- 
toms, spontaneous  fracture  being  usually  the  first  sign.  Other  kinds  of 
bone-cysts  have  been  seen  at  rare  intervals  in  the  tibia,  producing 
moderate  uniform  enlargement  of  the  bone  without  any  curvature, 
according  to  Schlange  because  the  fibula  acted  as  a  splint. 

The  treatment  of  these  bone-cysts  can  generally  be  made  conservative, 
consisting  in  chiselling  and  scraping  out  the  bone,  if  necessary,  in  doing 
an  osteoplastic  operation- 


CHAPTER  XXXV. 

OPERATIONS  ON  THE  LEG. 
EXARTICULATION  AT  THE  KNEE. 

This  operation,  which  was  formerly  avoided  as  much  as  possible  on 
account  of  the  supposed  greater  danger  of  infection,  is  now  often  per- 
formed, as  it  gives  an  excellent  stump.  A  circular  or  anterior  flap 
incision  may  be  made,  the  latter  being  the  one  usually  preferred. 

Flap  Incision. — The  limb  is  drawn  forward  beyond  the  edge  of  the 
table,  the  operator  grasps  the  calf  firmly  with  the  left  hand,  and  with 
the  knee  elevated  and  flexed  to  about  135  degrees,  makes  a  curved 
anterior  incision  comprising  about  two-thirds  of  the  circumference  of 
the  limb  with  its  base  just  below  the  cleft  of  the  joint  and  extending  in 
front  four  fingers'  breadth  below  the  spine  of  the  tibia.  The  flap  is 
dissected  back  up  to  the  line  of  the  joint  and  turned  up;  the  knee  is 
then  extended  and  a  posterior  transverse  incision  made  three  fingers' 
breadth  below  the  base  of  the  anterior  flap.  The  knee  is  then  flexed 
and  the  ligamentum  patella?,  capsule,  lateral  ligaments,  and  crucial 
ligaments  divided,  and  finally  the  posterior  wall  of  the  capsule  incised 
at  its  attachment  on  the  tibia,  and  the  amputation  completed  by  dividing 
the  muscles  behind  the  knee  transversely.  The  patella  can  generally 
be  saved;  if  not,  it  is  removed  subperiosteally.  The  popliteal  vein  and 
artery,  a  few  branches  of  the  articular  arteries,  and  the  larger  veins  of 
the  skin  are  to  be  ligated.  If  the  popliteal  divides  above  the  popliteal 
space,  both  branches  have  to  be  ligated. 

Circular  Incision. — The  incision  is  made  three  to  four  fingers'  breadth 
below  the  tibial  spine,  and  the  cuff  of  skin  and  fascia  is  dissected  back 
with  or  without  adding  a  longitudinal  incision  in  front  or  behind;  the 
suture-line  is  made  preferably  from  before  backward. 

AMPUTATION  OF  THE  LEO. 

The  leg  may  be  amputated  at  any  level.  If  removal  is  necessary 
above  the  middle  it  is  better,  in  view  of  the  artificial  limb  to  be  worn — 
at  least  in  the  case  of  poor  patients — to  amputate  high  up  below  the 
tibial  spine.  For  laborers  a  knee-stilt  is  to  be  preferred  upon  which 
the  flexed  stump  rests  with  its  anterior  surface.  The  choice  of  incision 
will  depend  upon  the  condition  of  the  soft  parts.  Those  methods  are 
preferable  which  give  the  longest  possible  stump  with  a  good  covering 
to  give  support  to  the  artificial  limb.     If  free  choice  is  possible,  a  circular 

(713) 


714  OPERATIONS  OH  THE  LEG. 

incision  is  generally  better  adapted  to  the  lower,  tendinous  part  of  the 
leg,  a  flap  incision  to  the  upper  part. 

If  a  circular  incision  is  chosen,  it  should  be  made  three  fingers'  breadth 
below  the  point  of  amputation,  and  include  skin  and  fascia.  The  dis- 
section of  the  cuff  is  facilitated  by  one  or  two  longitudinal  incisions, 
particularly  if  the  skin  is  densely  infiltrated.  The  muscles  should  be 
divided  square  across  while  the  cuffs  are  retracted;  a  strip  of  gauze  is 
then  passed  through  the  interosseous  space,  the  muscles  and  cuff  held 
back,  and  the  tibia  and  fibula  sawed  off  at  the  same  time;  it  is  a  mis- 
take to  saw  the  tibia  entirely  through  before  the  fibula.  The  periosteum 
is  peeled  back  from  the  front  of  the  tibia,  and  the  edge  of  the  bone  is  then 
rounded  off.  The  anterior  tibial  lying  on  the  interosseus  membrane 
and  posterior  tibial  on  the  deep  calf  muscles,  and  in  the  lower  two- 
thirds  the  peroneal  artery  on  the  posterior  surface  of  the  fibula,  or  of  the 
flexor  longus  pollicis,  are  to  be  fixated  with  their  accompanying  veins; 
also  a  number  of  smaller  arterial  branches  between  the  muscles,  and  the 
larger  subcutaneous  veins. 

If  flaps  are  made,  they  should  be  taken  from  the  sides;  the  conditions 
obtaining  in  each  case  will  determine  whether  the  flaps  are  to  be  of 
equal  size,  or  one  large  and  one  small,  as  is  more  frequently  the  case. 
The  base  of  the  large  flap  should  be  more  than  half  the  circumference 
of  the  leg  at  the  point  made.  The  flaps  should  comprise  skin  and 
fascia,  and  in  front  also  the  periosteum  of  the  tibia.  The  muscle  is  not 
included,  as  it  has  been  shown  that  it  atrophies  rapidly  and  completely, 
and  therefore  is  of  questionable  value.  The  danger  of  the  sharp  edge  of 
the  tibial  spine  perforating  the  anterior  flap  is  slight  in  a  clean  wound  if 
the  bandage  is  properly  applied,  and  is  lessened  by  rounding  off  the 
bone.  In  making  lateral  flaps  beginning  at  the  tibial  spine  care  should 
be  exercised  that  the  latter  is  well  covered.  After  dissecting  back  the 
flaps  the  rest  of  the  operation  is  as  described  above  under  circular  incision. 

Meusel  sought  to  prevent  pressure-necrosis  of  the  skin  by  throwing 
the  cuff  into  folds  over  the  edge  of  the  tibia  with  a  loop  of  thread.  To 
obviate  this  danger,  v.  Brans'  method  of  "subperiosteal"  amputation  is 
the  most  reliable:  A  circular  incision  is  made  down  to  the  bone  and 
two  lateral  longitudinal  incisions  1^  inches  long  made  directly  upon  the 
posterior  border  of  the  tibia  and  upon  the  fibula.  Through  these  three 
incisions  the  bones  are  shelled  out  subperiosteal!}'  and  sawed  off.  In 
this  manner  all  the  soft  parts  are  retained  in  their  normal  relation  in  the 
anterior  and  posterior  flaps.  The  method  gave  excellent  results  in  80 
amputations.  (Halm.)  With  appropriate  mechanical  after-treatment 
the  stumps  are  always  hard  and  resistant.     (Honsell.) 

If  operating  for  phlegmon  and  uncertain  as  to  whether  the  tissues  are 
infected  or  not,  or  if  speed  is  required  in  severe  accident  cases,  it  is 
urgently  recommended  not  to  close  the  wound,  but  to  pack  with  sterile 
or  iodoform  gauze  after  checking  the  bleeding,  to  apply  a  dressing  with 
slight  pressure,  and  to  close  the  wound  secondarily. 

The  stumps  obtained  by  the  above  methods  are  not  usually  capable  of 
bearing  the  full  direct  weight  of  the  body,  but  have  to  be  inserted  into 


LIGATION  OF  THE  ARTERIES  OF  THE  LEG.  715 

the  sheath  of  the  artificial  limb  in  such  a  manner  that  the  pressure  is 
brought  to  hear  upon  the  tuberosities  of  the  tibia,  the  condyles  of  the 
femur,  or  even  the  tuber  ischii.  To  make  the  end  of  the  stump  more 
resistant,  Bier  devised  an  osteoplastic  method  after  the  manner  of 
Ssabanejeff's  supracondyloid  amputation  of  the  femur  and  Pirogoff's 
amputation  of  the  foot.  After  several  trials  and  modifications  he 
recommended  the  following  technic:  A  large  skin-flap  is  formed  from 
the  front  and  inner  or  front  and  outer  side  of  the  leg,  and  dissected  back 
and  turned  up;  the  limb  is  then  amputated  through  a  circular  incision 
at  the  original  level  of  the  lower  margin  of  the  flap.  From  the  inner 
and  outer  surfaces  of  the  tibia  the  periosteum  is  then  peeled  off  in  such  a 
manner  that  while  still  adherent  to  the  anterior  surface  of  the  bone  it  is 
turned  up  against  the  stumps  attached  to  a  thin  plate  of  bone  sawed  from 
the  front  of  the  tibia  and  made  long  and  wide  enough  to  cover  the  stumps. 
After  sawing  off  the  tibia  and  fibula  at  the  level  of  the  base  of  the  skin-flap, 
enough  of  the  plate  of  bone  is  cut  off  above  so  that  the  intervening  hinge 
of  periosteum  is  not  stretched  in  turning  the  plate  up  against  the  surface 
of  the  stumps.  The  plate  is  then  adjusted  in  place  and  its  free  margin  of 
periosteum  sutured  to  that  of  the  stumps.  The  skin-flap  is  then  turned 
down  and  sutured.  The  modification  proposed  by  Storp  of  preserving 
the  connection  between  the  skin-flap  and  the  periosteal  bone  hinge- 
plate  appears  to  the  author  to  be  a  simpler  and  more  reliable  procedure: 
He  forms  a  large  flap  about  lh  times  the  diameter  of  the  leg  from  the 
front  and  inner  surface  so  that  the  front  surface  of  the  tibia  corresponds  to 
about  the  middle  of  the  flap,  dissects  it  off  upward  from  below  for  about 
1  to  1  §  inches  and  at  the  sides  to  the  lateral  borders  of  the  anterior  surface 
of  the  tibia,  then  makes  a  periosteum-bone-flap  of  appropriate  size,  pushes 
back  the  periosteum  slightly,  and  saws  off  from  below  upward  a  plate  of 
bone  \  inch  thick,  breaks  it  off  above  by  wedging  two  elevators  into  the 
saw  cleft  at  the  sides,  then  turns  it  back  and  amputates  at  the  level  of 
the  base  of  the  skin-flap. 

The  stump  obtained  by  Bier's  method  is  very  resistant.  More  recent 
experience  has  shown  meanwhile  that  equally  good  results  can  be 
obtained  with  the  old  amputation  methods  if  the  stump  is  massaged  and 
active  flexion  and  extension  of  the  knee  and  hip  carried  out  methodically 
in  connection  with  walking  exercises.     (Hirsch,  Honsell.) 


LIGATION  OF  THE  ARTERIES  OF  THE  LEG. 

At  the  present  time  it  is  customary  to  ligate  the  vessels  if  possible 
at  the  point  of  injury  or  disease,  so  that  it  is  only  exceptionally  neces- 
sary to  tie  the  main  trunks  at  a  chosen  spot  in  the  manner  still 
always  taught  on  the  cadaver.  The  anterior  tibial  artery  is  found  on 
the  interosseous  septum  in  a  line  drawn  from  midway  between  the  spine 
of  the  tibia  and  head  of  the  fibula  to  midway  between  the  malleoli,  and 
from  the  latter  point  to  the  first  metatarsal  interspace;  in  the  lower 
third  it  lies  between  the  tendons  of  the  tibialis  anticus  and  extensor 


716  OPERATIONS  ON  THE  LEG. 

longus  hallucis,  higher  up  between  the  tibialis  anticus  and  extensor  com- 
munis digitorum.  In  the  middle  and  upper  third  the  incision  has  to  be 
made  rather  long  and  the  firm  muscular  fascia  nicked  transversely 
above  and  below  the  point  of  ligation.  After  exposing  the  outer  border 
of  the  tibialis  anticus — in  the  middle  third  about  1£  inches  to  the  outer 
side  of  the  edge  of  the  tibia — and  dividing  the  fascia,  the  dissection  is 
carried  bluntly  between  the  muscles  down  to  the  septum,  and  the  artery 
isolated  from  the  anterior  tibial  nerve  lying  to  its  outer  side. 

The  posterior  tibial  artery  is  found  in  the  lower  third  midway  between 
the  inner  malleolus  and  the  tendo  Achillis,  lying  between  the  tendon  of 
the  flexor  digitorum  in  front  and  that  of  the  flexor  hallucis  behind  in  the 
common  sheath  containing  the  nerve.  In  the  middle  and  upper  third 
it  lies  among  the  deep  muscles,  between  the  soleus  and  tibialis  posticus 
1-|  inches  from  the  edge  of  the  tibia;  the  posterior  tibial  nerve  runs 
along  its  outer  side.  To  expose  the  artery  therefore  a  long  incision  is 
made  |  inch  from  the  inner  edge  of  the  tibia,  the  gastrocnemius  is 
retracted,  and  the  soleus  and  deep,  tense  fascia  divided. 


MALFORMATIONS,  INJURIES,  AND  DISEASES  OF  THE 
ANKLE  AND  FOOT. 

By  Prop.  De.  D.  NASSE  and  Dk.  M.  BORCHARDT. 


Anatomy  and  Physiology. — The  movements  of  the  foot  upon  the  leg 
take  place  chiefly  in  two  joints,  the  tibiotarsal  and  the  mediotarsal, 
between  which  the  astragalus  is  the  main  connecting  link. 

The  tibiotarsal  joint — talocrural,  ankle-joint,  Sprunggelenk,  Knochel- 
gelenk — formed  by  the  articular  surfaces  of  the  tibia  and  fibula  and  the 
trochlea  of  the  astragalus,  permits  of  motion  about  a  transverse  axis 


Fig.  445. 


Fig.  446. 


Voluntary  dorsal  flexion.  Voluntary  plantar  flexion. 

In  these  attitudes  the  astragalus  moves  with  the  foot  upon  the  leg  bones,  as  contrasted  with  adduc- 
tion and  abduction,  in  which  the  centre  of  motion  is  below  the  astragalus.    (Whitman.) 


passing  through  the  trochlea  at  the  level  of  the  tip  of  the  outer  malleolus, 
namely,  flexion  (dorsal  flexion)  and  extension  (plantar  flexion)  of  the  foot. 
Lateral  displacement  of  the  joint-surfaces  upon  each  other  is  prevented 
by  the  malleoli,  the  outer  extending  farther  down  than  the  inner.  The 
internal  and  external  lateral  ligaments,  attached  to  the  malleoli  and  to  the 
astragalus,  sustentaculum  tali,  and  scaphoid  on  the  inner  side,  and  to  the 

(717) 


718     MALFORMATIONS  AND  DISEASES  OF  ANKLE  AND  FOOT. 

astragalus  and  calcaneuro  on  the  outer  side,  respectively,  are  all  close  to 
the  transverse  axis  of  the  joint,  and  therefore  allow  motion  about  this 
axis. 

The  capsule  of  the  joint  is  attached  in  front  to  the  tibia  and  fibula 
along  the  border  of  the  cartilage,  and  extends  upward  somewhat  between 
the  bones;  on  the  astragalus  it  encloses  a  portion  of  the  neck  not  cov- 
ered by  cartilage;  it  is  partly  covered  by  the  extensor  tendons  and  sends 
pockets  and  folds  between  them.  At  the  sides  of  the  tendons  it  lies  very 
close  to  the  skin,  and  swelling  of  the  joint  is  first  visible  here.     Behind 


Fig.  447. 


Fig.  448. 


Voluntary  adduction.  Voluntary  abduction. 

In  these  postures  the  foot  moves  upon  the  astragalus,  which  is  practically  fixed  between  the 
malleoli.  Adduction,  the  turning  of  the  foot  inward  in  its  relation  to  the  leg,  is  always  accom- 
panied by  elevation  of  its  inner  and  depression  of  its  outer  border.  This  is  known  as  supination 
or  inversion  of  the  foot.  The  reverse  of  this  attitude — pronation  or  eversion — is  an  accompani- 
ment of  abduction,  as  is  illustrated  in  the  figures.    (Whitman.) 


and  on  the  sides  it  is  attached  along  the  edge  of  the  articular  cartilages. 
Beneath  the  outer  malleolus  the  limits  of  the  synovialis  closely  follow 
the  line  of  the  joint  between  the  astragalus  and  calcaneum.  Behind, 
the  space  between  the  attachment  of  the  plantaris  longus  on  the  posterior 
part  of  the  capsule  and  the  tendo  Achillis  is  filled  in  with  adipose  tissue. 
The  lateral  articular  surfaces  of  the  astragalus  converge  from  before 
backward;  during  flexion  of  the  foot,  therefore,  the  malleoli  approach 
each  other  and  are  slightly  separated  during  extension;  this  is  permitted 


MALFORMATIONS  AND  DISEASES  OF  ANKLE  AND  FOOT.     719 

by  the  elasticity  of  the  inferior  tibiofibular  ligaments.  The  range  <>f 
motion  in  the  tibiotarsal  joint  is  about  78  degrees,  and  is  composed 
about  equally  of  flexion  and  extension  measured  from  the  mid-position. 
(Weber  brothers.)  It  is  checked  partially  by  the  biarthrodial  and  poly- 
arthrodial  arrangement  of  the  muscles;  for  example,  with  the  knee 
Hexed,  the  range  of  flexion  of  the  foot  is  greater  than  with  the  knee 
extended.  Moreover,  extension  is  checked  by  the  anterior,  flexion  bv 
the  posterior  ligaments.  In  extension  the  posterior  margin  of  the  tibia, 
in  flexion  the  anterior  margin,  impinges  against  the  projecting  part  of 
the  astragalus. 

The  mediotarml  joint  (talotarsal)  is  composed  of  the  joints  between  the 
astragalus  and  scaphoid,  the  astragalus  and  calcaneum,  and  calcaneum 
and  cuboid,  motion  in  the  two  former  being  always  accompanied  by 
motion  in  the  latter.  The  movements  permitted  are  outward  rotation 
of  the  tip  of  the  foot — abduction — and  inward  rotation— adduction. 
In  abduction  the  outer  border  of  the  foot  is  also  raised,  and  the  inner 
border  lowered  at  the  same  time;  in  adduction  the  inner  border  is 
raised  and  the  outer  lowered;  this  rotation  about  the  long  axis  of  the 
foot  is  termed  pronation  (eversion)  and  supination  (inversion),  analo- 
gous to  the  rotation  of  the  hand,  and  as  abduction  and  pronation  and 
adduction  and  supination  cannot  be  carried  out  independently,  one 
often  speaks  merely  of  pronation  and  supination  of  the  foot.1  Motion 
takes  place  chiefly  between  the  astragalus  and  scaphoid,  but  also  simul- 
taneously between  the  calcaneum  and  cuboid,  hence  in  the  so-called  Cho- 
part's  joint-line.  The  articular  surface  of  the  head  of  the  astragalus  is 
not  spherical,  but  more  convex  laterally  than  from  above  downward. 
The  cotyloid  surface  of  the  scaphoid  moves  on  it  in  an  axis  directed 
from  the  tuberosity  of  the  calcaneum  forward  and  upward  to  the  head 
of  the  astragalus  at  an  angle  of  about  45  degrees  to  the  long  axis  of 
the  foot  in  the  mid-position.  As  this  axis  is  also  directed  somewhat 
inward,  the  front  of  the  foot  is  lowered  or  elevated  slightly  in  adduction 
or  abduction.  In  adduction  the  front  end  of  the  calcaneum  turns  inward 
and  downward  beneath  the  head  of  the  astragalus,  the  outer  surface 
turns  downward,  the  inner  upward.  This  rotation  is  transmitted  to  the 
cuboid  and  the  outer  border  of  the  foot  is  depressed  and  rotated  inward. 
The  range  of  motion  in  the  mediotarsal  joint  is  estimated  variously,  the 
highest  being  42  degrees.  It  is  checked  directly  only  in  the  calcaneo- 
astragaloid  joint  in  that  in  forced  abduction  the  anterior  process  of  the 
calcaneum  impinges  against  the  anterior  surface  of  the  free  outer  margin 
of  the  astragalus  in  front  of  the  external  malleolus,  and  in  forced  adduc- 

1  To  avoid  the  confusion  caused  occasionally  by  the  author's  use  interchangeably  of  abduction 
and  pronation  (eversion)  and  adduction  and  supination  (inversion),  the  terms  eversion  and  inver- 
sion will  be  used  to  signify  rotation  of  the  foot  about  a  horizontal  axis  (long  axis  of  foot),  and 
abduction  and  adduction  rotation  about  a  vertical  axis  (axis  of  leg).  Physiologically  considered, 
eversion  and  inversion  imply  a  certain  amount  of  abduction  and  adduction,  but  not  mechanically 
— e.g.,  in  pure  eversion  fractures  of  the  malleoli  and  pure  eversion  sprains  and  dislocations  of  the 
ankle.  Although  the  same  physiological  considerations  apply  inversely  to  abduction  and  adduc- 
tion, it  is  practical  for  the  sake  of  clearness  to  limit  abduction  and  adduction  to  rotation  about 
the  vertical  axis,  as  far  as  possible. 


720     MALFORMATIONS  AND  DISEASES  OF  ANKLE  AND  FOOT. 

tion  by  the  impingement  of  the  posterior  end  of  the  sustentaculum 
against  the  inner  margin  of  the  astragalus;  in  the  two  other  joints 
motion  is  limited  only  by  the  ligaments,  not  by  the  bones. 

The  internal  lateral  ligament  (deltoid  ligament),  together  with  the 
inferior  calcaneonavicular  ligament  covering  the  head  of  the  astragalus, 
prevents  abnormal  abduction  of  the  foot  and  sinking  of  the  arch  (flat- 
foot).  The  ligaments  in  the  sinus  tarsi  are  very  short  but  firm,  and 
hold  the  bones  together  without  preventing  motion,  as  they  lie  centrally. 
The  synovial  cavity  of  the  large  joint  between  the  astragalus  and 
calcaneum  is  separated  from  the  smaller  joint  between  the  sustentaculum 


Fig.  449, 


External  malleolar 
artery. 

External  malleolus. 


Tendon  of  the 
peroneus  brevis. 
Extensor  minimi 

digiti. 

Tendon  of  the, 
peroneus  tertins 


In terosseous  artery 

(I,  II,  III,  IV). 

Interosseous  m  usclei 

(I,  II,  III,  IV) 


Transverse  ligament  (upper  band 
of  anterior  annular  ligament). 


Anterior  tibial  artery. 
Anterior  tibial  nerve. 

Tendon  of  the  tibialis  anticus. 
Cruciate  ligament  (lower  band  of 

anterior  annular  ligament). 
Internal  malleolar  artery. 
Tarsal  branch  of  dorsalis  pedis  artery. 
—Dursalis  pedis  artery. 

Anterior  tibial  nerve. 
Tendon  of  the  extensor  longus  hallucis. 
Tendon  of  the  extensor  communis 
diffitorum. 
—  Dorsalis  hallucis  artery. 

Metatarsal  artery. 

Tendon  of  extensor  proprius  hallucis. 


Digital  brunches  of  the  dorsalis 
pedis  artery. 


Dorsal  surface  of  foot  and  ankle.     (Joessel.) 

and  neck  of  the  astragalus  in  front  by  the  ligaments  of  the  sinus  tarsi; 
the  smaller  joint  communicates  with  the  astragaloscaphoid  joint,  which 
in  turn  is  separated  from  the  synovial  cavity  of  the  calcaneocuboid  joint. 
The  topography  of  the  muscles,  tendons,  nerves,  and  vessels  is  pre- 
sumably well  known.  We  should  indicate  that  all  the  muscles  running 
to  the  foot  in  front  of  the  transverse  axis  of  the  tibiotarsal  joint,  namely, 
the  tibialis  anticus,  extensor  hallucis,  and  extensor  communis  digitorum, 
are  flexors  (dorsal  flexors)  of  the  foot,  those  behind  the  axis,  the  tibialis 
posticus,  flexor  digitorum,  flexor  hallucis,  the  peronei,  and  especially  the 
gastrocnemius  and  soleus,  are  extensors  (plantar  flexors).  All  these  mus- 
cles also  produce  rotation  about  the  oblique  sagittal  axis;  those  attached 


MALFORMATIONS  AND  DISEASES  OF  ANKLE  AND  FOOT.      721 

on  the  inner  side  of  the  axis  addud  and  invert:  tibialis  posticus,  flexor 
hallucis,  flexor  digitorum,  and  to  a  slight  extent   the  muscles  inserted 

in  the  tendo  Achillis.  The  tibialis  antieus,  beside  flexing,  inverts  the 
foot  somewhat,  as  it  runs  slightly  inward  from  the  oblique  axis  through 
the  head  of  the  astragalus.  The  extensors  also  invert  slightly.  The 
muscles  to  the  outer  side  of  the  axis  abduct  and  evert;  the  peronei 
most  actively,  the  extensor  digitorum  less  so. 

If  the  dorsum  of  the  foot  is  examined  while  the  foot  and  toes  are 
flexed  strongly,  it  will  be  seen  that  the  tendon  of  the  extensor  loneus 
hallucis  becomes  prominent  to  the  inner  side  of  the  middle  of  the  ankle 
(Fig.  449);  further  to  the  inner  side  the  tendon  of  the  tibialis  antieus 
diverges  from  it  toward  the  inner  border  of  the  foot;  to  the  outer  side  of 
the  extensor  hallucis  the  tendons  of  the  extensor  communis  digitorum 
radiate  to  the  second,  third,  fourth,  and  fifth  toes;  further  out  is  the 
tendon  of  the  peroneus  tertius  running  to  about  the  middle  of  the  outer 
border  of  the  foot.  Below  the  ankle  the  dorsal  artery  of  the  foot  can  be 
felt  between  the  tendon  of  the  extensor  longus  hallucis  and  the  first 
tendon  of  the  extensor  longus  digitorum.  The  lateral  margins  of  the 
upper  articular  surface  of  the  astragalus  can  be  felt  between  the  tendons, 
and  the  malleoli  if  the  foot  is  extended  strongly,  but  disappear  in  flexion. 
Beneath  the  external  malleolus  the  calcaneum  can  be  felt,  and  below  the 
internal,  the  prominent  sustentaculum  The  tuberosity  of  the  scaphoid 
is  palpable  beneath  the  skin  about  a  thumb's  breadth  in  front  of  the 
anterior  border  of  the  malleolus  on  the  inner  side  of  the  foot;  the  head  of 
the  astragalus  lies  deeply  situated  behind  it.  The  base  of  the  first  meta- 
tarsal lies  1 1  inches  in  front  of  the  scaphoid ;  the  first  cuneiform  between 
them  cannot  be  felt  distinctly.  On  the  outer  border  of  the  foot  the  base 
of  the  fifth  metatarsal  projects  at  about  the  middle.  The  bases  of  the 
first  and  fifth  metatarsals  give  the  position  of  Lisfranc's  joint;  the  line  of 
Chopart's  joint  lies  close  behind  the  tuberosity  of  the  scaphoid. 


Vol.  III.— 46 


CHAPTER  XXXYI. 

CONGENITAL    MALFORMATIONS    OF    THE    FOOT    (EXCEPT    CON- 
GENITAL CONTRACTURES). 

Congenital  hypertrophy  may  affect  the  entire  body,  one  side,  one  or 
both  extremities,  or  only  portions  of  the  same.  It  is  of  little  importance 
except  where  it  affects  only  the  lower  extremities,  and  especially  one. 
It  is  more  frequently  limited  to  parts  of  the  extremity  and  as  a  rule 
the  peripheral,  than  diffuse.  In  general  it  is  apparently  more  rare  in 
the  lower  than  in  the  upper  extremity.  True  hypertrophy  affects  all  the 
tissues  equally;  in  false  hypertrophy  the  increased  size  of  the  limb  is  due 
to  moderate  growth  of  one  particular  tissue.  True  hypertrophy  of  the 
entire  limb  is  very  rare,  but  of  parts  of  the  limb,  and  generally  of  the 
distal  portions  of  the  same,  somewhat  more  frequent.     (Fig.  450.)     The 

Fig.  4.50.  Fig.  451. 


Congenital  hypertrophy  of  the 
second  toe.  Child  eleven  years 
old.     (v.  Bergmann's  clinic.)  Hypertrophy  in  the  foot.  Supernumerary  digits.  (WittelsfaWer.J 

cases  of  false  hypertrophy  are  much  more  numerous.  Hypertrophy 
solely  or  chiefly  of  the  skeleton  is  practically  unknown.  In  connection 
with  diffuse  or  circumscribed  hypertrophy  of  the  soft  parts,  the  bones 
may  be  enlarged,  normal,  or  even  atrophic;  in  the  latter  case  the  con- 
dition approaches  the  congenital  forms  of  elephantiasis,  or,  if  the  hyper- 
trophy is  circumscribed,  the  congenital  tumors.  Hypertrophy  of  the 
adipose  tissue  is  the  most  common  form,  either  diffuse  over  the  entire 
limb  or  localized,  preferably  in  the  toes  and  foot.  (Fig.  451.)  Com- 
binations of  hypertrophy  with  other  malformations,  especially  syndac- 
tvlia,  are  not  infrequent.  All  forms  of  hypertrophy  are  accompanied 
rather  often  by  changes  in  the  vascular  system,  either  congenital,  such 
(722) 


CONGENITAL  MALFORMATIONS  OF  THE  FOOT.  72;; 

as  nee  v  us  vasculosus,  telangiectasis,  or  acquired,  as,  for  example, 
phlebectasis. 

As  to  the  changes  in  the  nerves  in  the  bypertrophied  limb:  Fischer 
claims  to  have  found  decreased  sensibility  in  the  hypertroph ied  part; 
Wagner  saw  a  painless  mal  perforant.  Increased  ephidrosis  and 
sensitiveness  to  cold  of  the  affected  parts  are  also  reported  rather  fre- 
quently. All  these  disturbances  may  be  of  a  secondary  nature  and 
due  to  circulatory  changes,  neuritis,  etc.,  but  their  similarity  to  the 
anomalies  of  the  nervous  system  demonstrated  in  acromegaly  is  striking 
and  deserves  further  study.  Abnormal  pigmentation,  resembling  that 
found  with  multiple  neurofibromata,  is  also  seen  in  all  cases  of  hyper- 
trophy. Such  multiple  nsevi  not  infrequently  represent  trophoneurotic 
disturbances;  similarly  multiple  lipomata,  and  particularly  diffuse 
lipoma,  have  been  referred  to  nervous  disturbances  the  nature  of  which 
is  still  obscure.  Anatomical  changes  in  the  nerves  have  never  been 
reported,  however,  either  in  true  or  false  hypertrophy;  the  cases  of 
neuritis  nodosa  were  apparently  elephantiasis  neuromatodes,  or  flexi- 
form  fibroneuromata.  The  etiology  of  congenital  hypertrophy  is  quite 
unknown. 

The  further  development  of  the  hypertrophy  apparently  varies 
according  to  its  nature;  in  some  instances  it  keeps  pace  with  the  growth 
of  the  body,  in  others  it  is  more  rapid.  Usually  it  remains  limited  to  the 
parts  first  attacked,  and  only  rarely  spreads  progressively  upward 
through  the  entire  extremity.  In  false  hypertrophy  the  growth  of  the 
affected  parts  is  apparently  more  rapid  than  that  of  the  rest  of  the  body, 
occasionally  becoming  more  rapid  after  being  stationary  at  first.  A 
permanent  arrestment  has  never  been  seen. 

Surgical  treatment  is  necessary  only  if  the  function  of  the  limb  is 
impaired.  Resection  or  excision  of  the  epiphyseal  cartilage  is  of  little 
use  except  in  favorable  cases.  As  a  rule  amputation  or  exarticulation 
is  necessary.  By  these  operations  the  hypertrophies  of  the  toes  which 
are  stationary  or  growing  at  the  rate  of  the  body  can  be  overcome.  But 
if  the  entire  extremity  is  involved  or  the  growth  advances  rapidly  upward, 
the  process  cannot  be  checked  even  by  early  operation,  as  shown  in  a 
case  of  Fischer's  of  rapid  hypertrophy  of  the  arm.  Operation  is  more 
often  necessary  in  the  case  of  false  hypertrophy  accompanied  by  the 
formation  of  tumors  in  the  soft  parts;  even  here  the  removal  must  be 
thorough  to  effect  a  permanent  cure.  If  the  growth  is  large  and  diffuse, 
or  if  the  bone  is  greatly  involved,  amputation  must  be  well  above  the 
disease  as  in  the  case  of  other  neoplasms.  Occasionally,  however,  a 
permanent  cure  is  impossible  if  there  are  lipomata  on  the  trunk  (Fischer) 
or  general  corpulence  develops  (Billroth  under  Wittelshofer).  Xon-opera- 
tive  measures,  of  which  compression  with  simple  or  elastic  bandages 
has  been  tried  the  most,  have  never  been  successful.  Even  in  the  cases 
of  telangiectasis  or  lymphangiectasis  they  were  only  palliative.  Con- 
genital elephantiasis  cannot  be  distinguished  sharply  from  false  hyper- 
trophy; it  is  less  frequently  limited  to  the  foot,  and  is  usually  more 
extensive.     Acquired  elephantiasis  is  as  a  rule  a  local  manifestation  of 


724  CONGENITAL  MALFORMATIONS  OF  THE  FOOT. 

disease  involving  the  entire  limb  to  a  varying  extent  (see  corresponding 
section). 

Supernumerary  digits  are  somewhat  more  common  than  hypertrophy, 
but  less  frequent  than  the  same  anomalies  in  the  upper  extremity.     The 

Fig.  452. 


Supernumerary  small  toe.     (v.  Bruns'  clinic.) 


changes  are  the  same  as  those  in  polydactylia  in  the  upper  extremity,  to 
the  description  of  which  the  reader  is  referred.  Eleven  toes  on  each 
foot  is  the  greatest  number  seen  thus  far.     Seven  to  nine  are  more  fre- 


Fig.  453. 


Supernumerary  toe.    (v.  Bruns'  clinic.) 


quent  and  six  most  frequent.  (Figs.  452  and  453.)  In  the  case  of  one 
or  two  supernumerary  digits,  they  are  almost  always  on  the  inner  or 
outer   side,  rarely   in    the    middle   of    the    foot.     The    coexistence    of 


CONGENITAL  MALFORMATIONS  OF  THE  FOOT. 


725 


supernumerary  fingers  and  toes  has  been  recorded  by  Vogt,  also  an 
heredity  through  several  generations.  It  is  significant  thai  where 
there  is  an  extra  toe  on  the  first  or  fifth  toe,  as  a  rule  only  the  phalanges 
arc  developed,  analogous  to  the  relations  in  the  hand,  while  the  meta- 
tarsal is  lacking.  According  to  Forster,  in  reduplication  of  the  other 
toes — or  fingers — not  only  the  phalanges  are  double,  but  also  frequently 
the  metatarsals  and  bones  of  the  tarsus.  Combinations  of  polydactylia 
and  syndactylia  occur  the  same  as  in  the  hand.     (Fig.  454.) 

Authors  still  disagree  as  to  the  genesis  of  polydactylia;  some  (K.  Bar- 
deleben)  assume  atavism  as  the  cause,  analogous  to  the  primitive  penta- 
dactylic  and  heptadactylic  forms  in  mammals;  others  (Gegenbauer) 
regard  it  as  a  malformation  in  the  strictest  sense,  due  to  disturbance 
in  the  primitive  trace.  In  the  majority  of  cases  it  must  be  referred 
to  external  causes  (trauma),  especially  constriction  by  amniotic  bands, 
as  verified  by  an  observation  of  Ahlfeld  of  an  amniotic  thread  attached 

Fig.  454. 


Polydactylia  and  syndactylia.     (Heynold.) 

at  the  point  of  cleavage  of  a  cleft  thumb.  The  same  methods  and  rules 
of  operation  apply  as  in  the  case  of  the  fingers.  A  case  of  macrodactylia, 
namely,  an  hypertrophied  hallux  with  three  members,  is  reported  by 
Hallmann. 

Deficiency,  the  antithesis  of  hypertrophy,  may  be  manifested  as 
brachydaetylia  or  microdactylia;  the  two  conditions  can  exist  simul- 
taneously in  the  same  toe  or  in  several  toes.  There  may  be  complete 
absence  of  one  or  all  toes,  ectrodactylia,  in  which  case  the  bones  of  the 
tarsus,  metatarsus,  the  leg,  or  even  the  thigh,  are  frequently  defective. 
In  addition  to  the  defects  there  are  frequently  adhesions,  syndactylia, 
and  exceptionally  supernumerary  digits,  polydactylia.  Many  of  these 
defects  are  irregular  in  form  and  extent  and  unquestionably  due  to 
amniotic  adhesions  or  bands,  constriction  by  the  umbilical  cord,  etc. 
The  evidence  of  such  causes  is  not  infrequently  found,  amniotic  threads, 
cicatrices,  grooves,  and  in  ectrodactylia,  a  peculiar  conical  stump  due  to 
amputation.     At  the  same  time  syndactylia  and  contractures,  such  as 


726 


CONGENITAL  MALFORMATIONS  OF  THE  FOOT. 


pes  varus,  valgus,  etc.  Other  defects  show  a  certain  regularity  and 
symmetry,  and  are  associated  with  analogous  defects  in  the  hands. 
Most  frequently  one  or  even  three  of  the  middle  toes  are  absent  if  the 
defect  does  not  extend  beyond  the  tarsus.  If  all  three  are  absent,  the 
middle  metatarsals  or  even  the  tarsals  may  be  absent  or  rudimentary. 
The  foot  then  appears  cleft  into  the  tarsus  (Figs.  455  and  456), 
and  resembles  the  same  condition  in  the  hand,  which  has  been  com- 
pared to  a  lobster  claw.  These  malformations  are  also  hereditary. 
Absence  of  the  marginal  toes  alone  is  rare,  but  in  combination  with 
defects  of  the  bones  of  the  leg  is  very  common.  Many  of  these  deformi- 
ties, in  which  there  is  undoubtedly  a  certain  amount  of  uniformity,  can 
be  referred  to  injurious  external  influences.  The  symmetry  does  not  posi- 
tively exclude  such  causes,  as  the  latter  can  affect  symmetrical  parts  of  the 
body  and  arrest  their  development  (for  example,  a  small  amnion,  pressure 


Fig.  455. 


Fig.  456. 


Ectrodactylia,  with  forking  of  the  tarsus.     (Pott.) 


of  the  uterus  due  to  lack  of  amniotic  fluid,  etc.).  But  it  is  hardly  pos- 
sible to  refer  defects  associated  with  a  distinct  heredity  to  adventitious 
external  influences.  Such  cases  suggest  faulty  construction  of  the 
primitive  trace.  In  accord  with  Wiedersheim,  Goldmann  represents 
the  development  of  the  foot  as  follows:  At  a  certain  stage  the  tarsus 
consists  of  three  parallel  rays  of  tissue,  each  divided  into  several  seg- 
ments (the  tarsal  bones),  the  tibial  and  medial  rays  later  forming  the 
first  two  toes.  From  the  fibular  ray,  which  is  derived  secondarily  from 
the  fibula,  are  formed  branches  representing  the  fourth  and  fifth  toes, 
and  the  basal  element  of  the  third  toe  from  which  the  third  toe  is  derived. 
The  first  two  rays  are  to  be  regarded  as  primary  rays.  The  first  of 
these  develops  into  the  tibia  and  the  hallux,  the  second  into  the  fibula 
and  second  toe,  while  the  other  toes  are  to  be  regarded  as  secondary 
offshoots  of  the  two  primary  rays,  with  the  exception  that  the  fourth  and 
fifth  toes  are  branches  of  the  secondary  ray  which  develops  into  the 


CONGENITAL  MALFORMATIONS  OF  THE  Four.  727 

third  toe.  This  theory  would  explain  why  defects  of  the  tibia  are  so 
apt  to  be  accompanied  by  absence  of  the  hallux,  and  why  with  defects 
of  the  fibula  the  four  outer  toes  arc  partially  or  completely  lacking;  but 
it  does  not  explain  why  the  fifth  toe,  the  last  offshoot  of  the  fibular  ray, 

is  so  constant,  that  it  is  present  with  the  hallux  in  the  absence  of  all  the 
other  fibular  branches,  or  even  occurs  alone  in  the  absence  of  all  the 
other  toes,  (ioldmann  tried  to  explain  the  absence  of  the  middle  toes 
by  external  conditions,  pressure  of  the  uterus;  aside  from  the  fact  that 
it  is  difficult  to  understand  this  on  mechanical  grounds,  there  is  the 
further  objection  against  Goldmann's  view,  that  these  defects  are  fre- 
quently symmetrical  in  the  hands  and  feet  and  that  they  are  inherited. 
In  general,  deficiencies  rarely  require  surgical  treatment  except  for  the 
accompanying  contractures,  syndactylia  or  polydactylia. 

Syndactylia  occurs  in  the  toes  to  the  same  extent  that  it  is  seen  in  the 
fingers.  The  middle  and  the  outer  toes  are  the  ones  most  frequently 
fused  together;  in  the  cases  reported  the  great  toe  is  adherent  less  often 
to  the  other  toes  than  the  thumb  is  to  the  index  finger.  The  failure  of 
the  skin  to  separate  between  the  toes  may  be  due  to  the  external  causes 
mentioned,  although  it  is  probably  referable  to  faulty  embryonal  con- 
struction, for  here  also  symmetry  and  heredity  are  important  factors. 
Operative  treatment  is  the  same  as  for  the  hands  and  as  described  by 
Vogt,  except  that  skin-grafting  is  more  frequently  employed  at  the 
present  time  to  cover  in  the  resulting  defects.  Operation  is  only  excep- 
tionally indicated,  however,  as  the  foot  even  with  one  or  all  toes  adherent 
is  useful  unless  other  deformities  exist. 

Defects  and  fusion  of  the  tarsals  occur  without  corresponding  mal- 
formations of  the  toes,  but  are  only  of  surgical  interest  if  followed  by 
contractures  and  faulty  position  of  the  foot. 


CHAPTER   XXXVII. 

INJURIES  OF  THE  ANKLE  AND  FOOT. 
SPRAINS  OF   THE  ANKLE-JOINT. 

A  SPRAIN,  namely,  stretching  and  partial  laceration  of  the  ligaments, 
is  frequently  the  result  when  the  various  forms  of  violence  which  ordi- 
narily produce  fracture  and  dislocation  are  applied  with  less  intensity 
or  are  more  quickly  exhausted.  It  is  a  very  common  injury,  and  may 
be  divided  into  two  groups,  sprain  by  eversion  and  by  inversion,  the 
former  being  less  frequent  than  the  latter  (see  p.  718,  ff).  In  sprains  by 
eversion  the  foot  is  usually  also  rotated  outward  at  the  tip  and  flexed, 
corresponding  to  the  physiological  movements,  and  in  those  by  inversion, 
also  rotated  inward  and  extended  (plantar-flexion ).  The  ligaments  on  the 
plantar  and  inner  surface  of  the  foot  are  very  strong,  so  that  forced 
eversion  or  outward  rotation  is  more  apt  to  fracture  the  malleolus  than 
to  tear  the  ligaments.  On  the  contrary,  sprain  is  an  extremely  common 
result  if  the  foot  is  twisted  inward.  If  this  happens  without  much 
inward  rotation  of  the  tip  of  the  foDt  (adduction),  the  calcaneo-astraga- 
loid  ligaments  and  those  below  and  in  front  of  the  external  malleolus  and 
on  the  dorsal  outer  surface  of  the  astragaloscaphoid  joint  are  torn.  The 
most  frequent  site  of  tenderness  and  ecchymosis  is  therefore  below  and 
in  front  of  the  external  malleolus.  On  the  other  hand,  if  inward  rotation 
(adduction)  of  the  foot  predominates,  the  joints  between  the  calcaneum 
and  cuboid  and  between  the  scaphoid  and  cuneiforms  are  more  often 
contused;  the  ecchymosis  is  then  farther  forward.  The  diagnosis  is 
made  by  the  tenderness,  ecchymosis,  and  the  absence  of  fracture  of  the 
malleoli  or  of  the  tarsal  bones.  Larger  effusions  of  blood  are  apt  to  fill 
or  surround  the  ankle-joint  and  conceal  fractures  of  the  malleoli  or 
avulsion  of  small  fragments  of  bone.  So  that  in  the  absence  of  displace- 
ment, such  fractures  are  very  often  overlooked  and  treated  as  sprains. 
Therefore  in  all  doubtful  cases  the  injury  should  be  treated  as  a  fracture. 

Treatment. — Massage  has  been  properly  recommended  to  remove 
the  effusion  of  the  blood  in  slight  sprains;  the  patient  may  be  allowed 
to  go  about  wearing  a  supporting  and  compressing  bandage.  Gibney's 
adhesive  plaster  dressing  is  well  recommended  for  ambulant  treatment 
(Fig.  457),  but  is  advisable  only  for  slight  injuries.  In  severe  cases  of 
sprain,  in  which  extensive  laceration  of  the  ligaments  is  suspected  from 
the  marked  extravasation,  we  consider  it  best  to  immobilize  the  foot  in  a 
strip  (see  Fig.  466,  p.  740),  or  plaster-of-Paris-splint  for  two  to  two 
and  a  half  weeks;  later  massage  and  active  and  passive  motion  are 
carried  out.  ^Ye  prefer  this  method  to  the  use  of  ice-bags  and  massage, 
so  frequently  employed  to  limit  or  remove  extravasation,  because  it 
insures  the  firmest  union  of  the  torn  ligaments.  In  simple  sprains 
(728) 


INJURIES  OF  THE  TENDONS. 


729 


the  fixation  does  not  produce  serious  stiffness,  and  without  fixation  the 
repair  of  the  ligaments  is  only  partial.  In  the  latter  case  the  result  is 
weakness  of  the  ligaments  and  an  instability  of  the  foot  which  leads  to 


Fig.  457. 


■  -  -  - 


Gibney's  adhesive  plaster  dressing. 


frequent  recurrence.  This  explains  many  habitual  sprains.  On  the 
other  hand,  under  appropriate  treatment  a  sprain  should  recover  without 
leaving  any  functional  disturbance. 


INJURIES   OF   THE   TENDONS. 

Dislocation  of  the  Tendons  of  the  Foot. — At  the  point  where  the 
tendons  of  the  peroneal  muscles  pass  under  the  outer  malleolus  they 
are  retained  in  a  deep  groove  by  two  strong  bands,  the  retinaculum 
superius  and  inferius.  The  upper  transverse  fibres  represent  part  of 
the  fascia  of  the  leg,  the  lower  band  forms  a  loop  attached  to  the  cal- 
caneum.  If  these  are  torn,  the  tendons  may  be  displaced  to  an  extent 
corresponding  to  the  severity  of  the  tear.  This  rather  rare  injury  is 
usually  due  to  violent  contraction  of  the  muscles  of  the  calf  in  the  effort 
to  prevent  the  foot,  twisted  inward,  as  in  jumping,  from  being  twisted 
further,  the  tendons  being  torn  from  the  grooves  by  the  sudden  forcible 
abduction  and  plantar  flexion  of  the  foot.  The  foot  is  disabled;  the 
outer  malleolus  appears  to  be  thickened;  the  tendons  can  be  rolled 
about  beneath  the  finger.    If  only  one  tendon  is  displaced,  it  is  commonly 


730  INJURIES  OF  THE  ANKLE  AND  FOOT. 

the  peroneus  Longus.  Usually  the  tendons  are  easily  reducible,  often 
slipping  back  with  a  snap,  but  become  reluxated  if  the  foot  is  abducted. 

Treatment. — The  treatment  consists  in  replacing  the  tendons,  apply- 
ing a  graduated  compress,  and  over  this  a  bandage;  or,  adhesive  plaster 
strips  are  applied  over  and  parallel  to  the  tendons.  The  foot  is  then 
immobilized,  preferably  in  slight  inversion.  Many  cases  recover  in 
this  way;  in  others,  in  spite  of  protracted  treatment,  the  tendons  slip 
out  of  place;  in  recent  cases  the  torn  bands  may  be  sutured  back  in 
place  with  catgut. 

If  the  dislocation  becomes  old  or  habitual,  locomotion  becomes 
hampered  and  unsteady,  the  slipping  back  and  forth  of  the  tendons 
being  very  annoying.  Of  the  various  operations  proposed,  those  of 
Konig  and  Kraske  have  been  most  successful:  A  flap  of  bone  and  peri- 
osteum is  turned  down  and  over  the  tendons  so  that  the  periosteum  lies 
against  them  and  is  then  sutured  to  the  bone  behind  them.  The  same 
dislocation  occurs  as  a  complication  of  fracture  and  requires  appropriate 
treatment.  Martins  reports  a  dislocation  of  the  tendon  of  the  tibialis 
posticus  forward  in  front  of  the  inner  malleolus;  reduction  and  retention 
were  simple  and  were  followed  eventually  by  complete  recovery  although 
the  foot  was  disabled  for  some  time  afterward. 

Laceration  of  the  Tendons  of  the  Foot.— The  tendo  Achillis  is  some- 
times torn  by  the  action  of  violence  similar  to  that  which  produces 
fractures  of  the  tuberosity  of  the  calcaneum.  Often  the  tear  is  only 
partial;  but  the  gap  between  the  separated  stumps,  the  swelling  about 
the  tear,  and  the  loss  of  function  are  diagnostic.  Recovery  is  by  fibrous 
union,  similar  to  that  which  forms  after  tenotomy.  If  the  stumps  are 
separated  to  any  extent  or  the  sheath  torn,  the  long  fibrous  cicatrix  which 
forms  is  inadequate,  so  that  the  strength  of  the  muscles  of  the  calf  is 
greatly  reduced.  We  have  seen  numerous  such  cases.  If  the  tendon 
is  completely  divided  by  an  open  wound,  the  stumps  are  usually  sepa- 
rated widely  and  become  adherent  to  the  sheath  at  the  level  of  retraction 
without  any  fibrous  union  forming  between.  If  the  wound  is  infected 
the  inflammation  may  extend  up  to  the  calf.  Subcutaneous  laceration 
of  the  other  tendons  is  not  known,  except  a  case  of  the  plantaris 
longus  which  was  followed  by  complete  recovery.  Open  division  is 
frequent. 

Treatment. — In  case  of  subcutaneous  laceration  with  slight  separa- 
tion one  may  attempt  to  approximate  the  stumps  by  flexing  the  knee 
and  extending  the  foot  and  immobilizing  the  limb  in  this  position  for 
two  to  three  weeks  with  a  posterior  or  circular  plaster-splint;  later, 
passive  motion  is  begun  but  active  motion  not  for  some  time,  as  the 
fibrous  bridge  between  the  stumps  is  easily  stretched.  We  saw  a  case 
of  a  jumper  (a.  clown  |  in  whom  the  function  was  completely  restored 
in  this  manner.  If  the  stumps  are  widely  separated,  they  may  be 
sutured  together.  In  v.  Bergmann's  clinic  this  was  done  successfully  in 
the  case  of  a  circus-rider,  but  was  extremely  difficult  on  account  of  the 
fraying  out  of  the  stumps.  Open  division  requires  suture  under  strict 
antisepsis;  a  splint  is  applied  in   the  same  way  as  for  subcutaneous 


FRACTURES  ABOVE  THE  MALLEOLI. 


731 


laceration.  If  the  tendon  has  united  by  a  long  fibrous  bridge,  the 
stumps  should  be  exposed,  freshened  up,  and  sutured  while  the  knee  is 
held   flexed   and   foot   extended.     The  operation   has   been   successful 

repeatedly.  The  treatment  of  open  division  of  the  other  tendons  is  on 
general  principles. 

Laceration  of  the  plantar  fascia  has  been  seen  associated  with  frac- 
tures of  the  malleoli  and  other  injuries  of  the  foot ;  in  a  number  of  eases 
the  resulting  fibrous  union  was  excessive  in  the  form  of  nodules  which 
persisted  for  months  or  years;  usually  the  nodules  disappeared  spon- 
taneously but  with  a  resulting  contraction  of  the  fascia,  analogous  to 
Dupuytren's  contraction  of  the  palmar  fascia.  Ledderhose  studied  the 
process  closely  and  found  that  the  nodules  appeared  mostly  after  immo- 
bilizing splints  had  been  worn  and  during  the  first  attempts  at  walking. 
He  is  inclined  to  regard  it  as  an  atrophic  disturbance  in  the  fascia  due  to 
laceration,  the  action  of  the  splint,  etc.;  a  reactionary  proliferation  of 
the  fascia  follows,  analogous  to  that  known  to  occur  in  other  tissues; 
the  fascia,  as  a  result  of  this  "fasciitis  chronica,"  is  less  resistant,  is 
easily  ruptured,  and  heals  by  excessive  nodular  cicatrices.  In  a  few 
cases  the  nodules  were  so  troublesome  in  walking  that  he  was  obliged 
to  excise  them. 

FRACTURES  ABOVE   THE  MALLEOLI. 

Those  fractures  are  termed  supramalleolar  (Malgaigne)  which  are 
situated  from  *  to  1  inch  above  the  line  of  the  tibiotarsal  joint;  as  a  rule 


Fig.  458. 


Fig.  459. 


Supramalleolar  fracture  with  partial  separation  oi  the  epiphysis  combined  with  oblique  lracture  01 

the  tibia,     (v.  Bruns'  clinic.) 


732 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


Fig.  460. 


they  involve  the  joint.  They  may  be  due  to  direct  violence,  such  as 
run-over  accidents,  etc.,  but  are  more  frequently  caused  by  falling  from 
a  height,  the  foot  at  the  same  time  being  twisted  inward  or  outward. 
The  astragalus  thus  wedges  the  malleoli  apart.  Exceptionally  there  is 
merely  laceration  of  the  tibiofibular  ligaments  and  the  bones  become 
separated;  but  usually  there  is  a  longitudinal  fracture  of  the  tibia  along 
its  outer  margin.  If  the  force  is  continued,  the  tibia  may  be  broken 
by  inflexion  close  above  the  joint.  This  happens  more  frequently  by 
adduction  than  by  abduction  of  the  foot.  Tillaux  produced  the  frac- 
ture experimentally  by  forced  adduction,  and  believes  that  after  the  fibula 
has  yielded  in  the  lower  third  the  inferior  tibiofibular  ligaments  pull  on 
the  tibia  so  that  the  latter  is  broken  on  its  outer  side  by  avulsion  and  on 

the  inner  side  by  inflexion.  As  a  matter 
of  fact  supramalleolar  fracture  occurs 
most  frequently  if  the  foot  is  everted 
by  the  fall.  The  same  mechanism  is 
caused  by  a  false  step,  in  that  with  the 
foot  fixed  the  weight  of  the  body 
breaks  the  obliquely  directed  leg  above 
the  malleoli.     (Konig,  Reinhardt.) 

The  fracture-line  varies  greatly.  (Fig. 
458  to  Fig.  400.)  It  may  be  transverse 
through  both  bones,  or  irregularly  ser- 
rated ;  often  a  fragment  of  the  articular 
surface  of  the  tibia  is  torn  off  behind  or 
in  front.  As  stated,  a  longitudinal  frag- 
ment may  be  torn  from  the  outer  sur- 
face of  the  tibia.  The  lower  fragments 
of  the  tibia  and  fibula  are  frequently 
broken  into  several  pieces;  the  upper 
fragment  of  the  tibia  may  become  im- 
pacted in  the  lower  or  slip  down  beyond 
it  and  impinge  against  the  os  calcis. 

Symptoms. — The  symptoms  are  very 
irregular.  If  the  fragments  are  merely 
displaced  laterally,  the  ankle  is  broad- 
ened; in  other  instances  the  foot  is  twisted  sideways,  most  frequently 
everted,  so  that  the  condition  may  resemble  a  lateral  dislocation, 
but  the  bony  prominence  above  the  line  of  the  joint  on  the  convex 
side  is  diagnostic.  Or  the  tibia  and  fibula  may  be  separated  and 
the  foot  become  displaced  upward  in  the  interosseous  space,  or  back- 
ward and  upward  with  the  upper  fragment  of  the  tibia  lying  on  the 
front  of  the  astragalus  and  so  resembling  backward  dislocation  of 
the  foot. 

Diagnosis. — The  diagnosis  may  be  difficult  as  the  swelling  is  usually 
pronounced.  Careful  palpation  is  therefore  necessary.  As  this  is 
painful,  an  accurate  coaptation  of  the  fragments  is  difficult.  Hence, 
anaesthesia  is  usually  desirable. 


Supramalleolar  fracture.      Union  with 
deformity.      (v.  Bruns.) 


FRACTURES  OF  THE  MALLEOLI. 


7:;:j 


Prognosis. — The  prognosis  is  unfavorable.  As  a  rule  the  period  of 
recovery  extends  over  three  months,  and  a  definite  decision  as  to  the 
usefulness  of  the  foot  is  frequently  impossible  within  a  year.  Deformity 
and  impaired  motion,  or  even  ankylosis,  are  frequent. 

Treatment.—  The  treatment  is  the  same  as  that  of  fractures  of  the 
malleoli. 


FRACTURES  OF  THE  MALLEOLI  (POTT'S  FRACTURE). 

Fractures  of  the  malleoli  are  the  most  frequent  fractures  of  the 
leg  next  to  those  of  the  shaft  of  both  bones  of  the  leg.  In  the  large 
majority  of  cases  they  are  due  to  indirect  violence;  exceptionally  to  direct 
violence,  such  as  a  blow  or  fall  upon  the  inner  or  outer  side  of  the  leg. 

Mechanism. — In  their  mechanism  of  origin  indirect  fractures  of  the 
malleoli  cannot  be  distinguished  from  sprains  or  lateral  dislocations  of 
the  ankle-joint.  All  these  injuries  are  produced  by  twisting  of  the  foot 
upon  uneven  ground,  or  by  falling  sideways  while  the  foot  is  fixed,  for 
example  in  a  hole,  railroad  track  or  between  rocks,  or  by  violent  rotation 
of  the  leg  while  the  foot  is  fixed,  or  by  the  foot  being  everted  or  inverted 
forcibly  against  the  ground  in  jumping  or  falling.  The  effect  is  there- 
fore essentially  an  exaggeration  of  the  physiological  movements  of  the 
tibiotarsal  joint,  either  inversion  or  eversion — that  is,  rotation  about 
the  long  axis  of  the  foot,  or  abduction  or  adduction,  namely,  rotation 
about  an  imaginary  vertical  axis  through  the  leg.  That  as  a  rule  the 
tibiotarsal  joint  rather  than  the  mediotarsal  joint  is  injured  by  these 
movements  is  due  to  the  fact  that  owing  to  the  strength  of  the  ligaments 
of  the  mediotarsal  joint  and  to  the  contraction  of  the  muscles  at  the 
moment  of  injury  the  foot  transmits  the  force  like  a  stiff  lever-arm  to 
the  tibiotarsal  joint.  If  the  force  is  quickly  spent,  it  merely  produces 
laceration  or  partial  rupture  of  the  ligaments — that  is,  a  sprain;  but  if 
it  acts  more  energetically,  the  ligaments  usually  prove  more  resistant  than 
the  bone,  so  the  latter  is  fractured  by  avulsion  on  the  side  of  the  convex- 
ity, namely,  by  eversion  a  fragment  of  the  tibia  is  torn  off  and  by  inversion 
of  the  fibula  (fracture  par  arrachement).  In  addition,  however,  another 
factor  comes  into  play.  The  astragalus  is  rotated  violently  at  the  same 
time  and  so  wedges  the  tibia  and  fibula  apart  with  rupture  of  the  inter- 
osseous ligament  or  forces  off  one  of  the  malleoli  (fracture  par  divulsion). 
In  fractures  of  the  malleoli  these  two  forces,  pressure  and  traction,  are 
usually  combined.  If  the  force  is  continued  after  the  fracture  has  been 
produced,  the  astragalus  becomes  dislocated  laterally.  There  is  there- 
fore a  lateral  dislocation  of  the  foot,  a  thing  which  happens  very  seldom — 
as  can  be  understood  from  the  above  considerations — without  fracture 
of  the  malleoli.  The  difference  between  fractures  of  the  malleoli  and 
lateral  dislocations  of  the  foot  is  merely  one  of  degree,  hence  the  rather 
appropriate  term  "dislocation  fractures."     (Stromeyer.) 

For  a  long  time  experiments  have  been  made  on  the  cadaver  to  deter- 
mine the  mechanism  of  fractures  of  the  malleoli.     (Dupuytren,  Maison- 


734  INJURIES  OF  THE  ANKLE  AND  FOOT. 

neuve,  Bonnet,  Tillaux,  Honigschmied.)  Forcible  eversion  and 
inversion  of  the  foot,  namely,  rotation  about  its  long  axis,  was  termed 
fibular  flexion  and  tibial  flexion  by  many  authors,  as  applied  to  the 
transmission  of  these  movements  to  the  tibiotarsal  joint.  The  foot  was 
also  forcibly  adducted  and  abducted — that  is,  rotated  about  a  vertical 
axis  through  the  leg.  It  was  thus  sought  to  demonstrate  which  move- 
ments in  the  tibiotarsal  joint  produced  the  various  forms  of  fracture. 
In  the  living  subject  these  forces  do  not  act  separately,  however,  but 
rather  adduction  and  inversion  (supination)  and  abduction  and  eversion 
(pronation)  are  usually  combined,  corresponding  to  the  physiological 
movements  of  the  tibiotarsal  joint.  We  distinguish,  accordingly, 
adduction  or  inversion  fractures  and  abduction  or  eversion  fractures. 
[The  author  classifies  as  inversion  or  eversion  fractures  those  in  which 
the  dominant  force  is  violent  adduction  or  abduction,  corresponding  to 
our  adduction  and  abduction  fractures.] 

Fractures  by  Inversion  and  by  Adduction. — If  while  the  foot 
is  fixed  the  body  falls  to  the  tibial  side,  or  if  the  foot  is  twisted  inward 
by  a  misstep  or  in  jumping,  or  if  while  the  leg  is  fixed  the  foot  is  driven 
violently  inward  and  upward,  the  tibiofibular  and  external  lateral 
ligaments  are  put  upon  the  stretch  and  the  latter  tears  the  external 
malleolus  off  at  or  above  its  point  of  insertion  if  it  is  stronger  than 
the  bone;  the  result  is  a  transverse  or  slightly  oblique  fracture  about 
f  inch  above  the  tip  of  the  malleolus.  If  the  force  is  continued,  the 
astragalus  is  driven  inward  against  the  internal  malleolus  and  breaks  it 
partly  or  completely  off;  if  the  fragment  becomes  displaced,  the  foot 
stands  in  the  varus  position. 

The  symptoms  of  this  fracture  are  not  usually  pronounced.  If  only 
the  fibula  is  broken,  the  break  is  often  an  infraction  without  displace- 
ment, false  motion,  or  crepitus,  the  only  sign  being  a  fixed  point  of 
tenderness  on  the  malleolus.  There  is  an  effusion  of  blood  in  the  joint. 
The  patient  is  often  able  to  walk.  The  fracture  is  therefore  not  infre- 
quently mistaken  for  simple  sprain.  On  the  other  hand,  if  the  peri- 
osteum of  the  fibula  is  torn  through  completely,  the  edges  of  the  frag- 
ments and  the  groove  between  them  can  be  felt  and  crepitus  and  false 
motion  usually  elicited.  In  the  same  manner  fracture  of  the  internal 
malleolus  may  be  without  any  displacement  and  only  evidenced  by  a 
localized  point  of  tenderness. 

If  the  force  rotates  the  foot  principally  inward  about  the  vertical  axis 
of  the  leg,  there  may  be  merely  a  sprain  with  laceration  of  the  external 
lateral  ligament  and  the  ligaments  of  Chopart's  joint;  or  there  may  be 
a  fracture  of  the  fibula  above  the  external  lateral  ligament,  or  a  torsion 
fracture  of  the  tibia  and  fibula  due  to  rotation  of  the  astragalus.  These 
adduction  fractures  (the  author's  "inversion  fractures")  are  rare.  In 
all  the  forms  of  inversion  and  adduction  fractures  the  displacement  is 
rarely  marked  unless  the  ligaments  are  extensively  torn;  the  foot  is 
then  adducted;  the  astragalus  is  twisted  so  that  the  trochlea  faces  the 
external  malleolus  and  its  under  surface  faces  inward.  It  is  therefore 
dislocated.     Displacement  in  a  horizontal  direction  is  less  frequent. 


Fll.UJTURES  OF  THE  MALLEOLI, 


735 


Fractures  by  Eversion  and  by  Abduction.— These  forms  are 
much  less  frequent  than  the  above,  and  are  produced  similarly  but  in 
the  opposite  direction  by  violent  eversion  or  abduction  of  the  foot.  If, 
for  example,  the  entire  foot  is  held  firmly  while  the  body  falls  outward, 
the  deltoid  ligament  is  put  on  the  stretch;  it  is  rarely  torn,  bul  usually 
tears  off  the  internal  malleolus,  and  as  a  rule  near  its  base;  exceptionally 
the  ligament  is  torn  off  at  its  insertion  on  the  astragalus.  The  force 
continued  drives  the  calcaneum  against  the  tip  of  the  external  malleolus; 
the  latter  may  be  crushed.  The  mechanism  is  commonly  a  different  one, 
however;  while  the  astragalus  and  calcaneum  press  the  external  malleolus 
outward,  the  weight  of  the  body  forces  the  leg  and  the  shaft  of  the  fibula 


Fig  4fil 


Fig.  462. 


Typical  eversion  fracture  of  the  malleoli, 
(v.  Bruns.) 


Fracture-lines  of  avulsion  fractures  of  the 
outer  part  of  tibia,  with  fracture  of  internal 
malleolus.    Diagrammatic,     (v.  Volkmann.) 


inward.  The  entire  weight  of  the  body  thus  rests  upon  the  fibula  as  it 
impinges  against  the  calcaneum  and  the  fibula  breaks  at  its  weakest 
point  above  the  tibiofibular  ligaments,  namely,  2  to  2[  inches  from  the 
tip.  The  typical  form  of  this  fracture  by  eversion  is  therefore  a  tear- 
fracture  of  the  internal  malleolus  and  secondary  inflexion  fracture  of 
the  fibula  above  the  joint  (typical  Pott's  fracture).     (Fig.  461.) 

By  this  mechanism  the  tibiofibular  ligaments  are  always  stretched  to 
the  utmost  whether  the  typical  fracture  occurs  or  not.  These  ligaments 
may  give  way,  the  tibia  and  fibula  may  be  pushed  apart — diastasis — 
and  the  astragalus  become  wedged  between  the  bones  in  the  interos- 
seous  space;  or  if  the  ligaments  are  stronger  than  the  bone  the  external 
malleolus,  pressed  upward  and  outward,  may  tear  off  a  fragment  from 


736 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


Fig.  463. 


the  tibia,  (v.  Volkmann.)  (Fig.  462.)  If  the  injury  results  from  falling 
from  a  height,  the  direct  pressure  of  the  <\--;agalus  is  unquestionably 
concerned  in  breaking  off  the  fragment  t  .*..  the  outer  border  of  the 
tibia.  The  fracture-line  in  the  tibia  is  usually  very  oblique  from  above 
downward  and  inward;  the  base  of  the  wedge-shaped  fragment  may  be 
very  small  or  include  the  entire  articular  surface  of  the  tibia. 

According  to   the  degree  of  violence,   the  fragments  may  be  only 
slightly  displaced  and  the  foot  stand  approximately  in  its  normal  position; 

or  the  astragalus  may  be  rotated  on  its  sagittal 
axis  till  the  trochlea  faces  the  internal  malleo- 
lus, the  so-called  outward  dislocation  of  the 
foot.  Exceptionally  the  astragalus  is  dislo- 
cated horizontally  at  the  same  time.  In  those 
very  severe  cases  of  dislocation  the  skin  is 
stretched  tightly  over  the  internal  malleolus  and 
may  give  way  or  be  transfixed  by  the  upper 
fragment  of  the  tibia.     (Fig.  463.) 

In  many  instances  the  violence  acts  less  in 
the  sense  of  everting;  the  astragalus  and  cal- 
caneum  than  in  abducting  or  rotating  the  tip 
of  the  foot  outward  (eversion  fracture  of  the 
author).  For  example,  if  the  foot  is  fixed  or 
wedged  and  the  body  and  leg  are  rotated  in- 
ward while  falling,  or  when  a  rider  hangs  by 
the  stirrup,  or  if  while  in  the  saddle  his  foot  is 
twisted  backward  by  striking  a  tree  or  wall.  In 
all  these  instances,  as  the  tarsal  joints  are  fixed, 
the  foot  represents  a  lever  perpendicular  to  the 
malleoli,  which  it  forces  apart.  The  internal 
malleolus  is  thus  pressed  forward  and  inward 
by  the  inner  surface  of  the  astragalus  and  the 
outer  malleolus  is  pressed  outward  and  back- 
ward by  the  outer  surface,  usually  followed  by 
fracture  of  the  fibula.  The  fracture  begins 
wTith  the  tearing  off  of  a  triangular  fragment 
from  the  lower  end  of  the  tibia,  corresponding 
to  the  attachment  of  the  anterior  tibiofibular 
ligament,  the  force  is  continued  from  in  front 
and  to  the  inner  side  upward  and  outward 
through  the  fibula,  so  that  the  fibula  is  broken 
off  at  a  higher  level  than  the  tibia,  the  lower 
fragment  ending  behind  and  to  the  inner  side 
in  a  sharp  point.  The  lower  fragments  may  be  displaced  outward 
with  the  foot  so  that  the  trochlea  of  the  astragalus  comes  to  lie  below 
the  upper  fragment  of  the  fibula.  Less  frequently  only  the  tip  or  the 
posterior  part  of  the  external  malleolus  is  torn  off  by  the  posterior 
fasciculus  of  the  external  lateral  ligament. 

The  displacement  of  the  fragments  in  these  abduction  fractures,  and 


Eversion  fracture  with  marked 
dislocation  and  laceration  of  the 
skin  under  the  internal  mal- 
leolus.   (Anger.) 


FRACTURES  OF  THE  MALLEOLI. 


737 


thereby  the  displacement  <>l"  the  astragalus,  may  be  such  that  the  astrag- 
alus is  rotated  outward  9(7  degrees  on  its  vertical  axis  and  the  foot 
points  outward;  this  typa  of  dislocation  has  been  termed  outward 
rotation-dislocation. 

Symptoms. — The  symptoms  of  all  these  abduction  and  (version 
fractures  are  obviously  very  diverse.  A  characteristic  picture  can  be 
drawn  only  for  the  typical  eversion  fracture,  the  elements  of  which  are 
a  tear-fracture  of  the  internal  malleolus  and  a  supramalleolar  fracture 
of  the  fibula.  Usually  the  foot  is  distinctly,  although  only  slightly, 
abducted  and  everted,  namely,  in  the  valgus  position.  The  prolonga- 
tion of  the  axis  of  the  tibia  which  ordinarily  passes  between  the  first  and 
second  toes,  falls  to  the  inner  side  of  the  foot;  this  deviation  may  be  due 
either  to  abduction  or  to  eversion  of  the  foot  as  a  unit.  The  upper  frag- 
ment of  the  tibia  projecting  beneath  the  skin  makes  the  region  of  the 
internal  malleolus  more  prominent.  The  malleoli  appear  broadened 
in  consequence  of  the  outward  displacement  of  the  external  malleolus. 
On  the  outer  side  of  the  leg  above  the  joint  there  is  an  angular  deformity 
corresponding  to  the  fracture  of  the  fibula.  The  deformity  is  readily 
increased  by  manipulation  and  also  becomes  more  marked  if  the  patient 
attempts  to  walk. 

All  these  symptoms  may  be  wanting  in  the  absence  of  displacement, 
the  only  evidence  of  fracture  being  the  functional  loss  and  extravasation 
of  blood.  The  latter  is  greater  than  in  simple  sprain;  it  extends  along 
the  tibia  and  fibula,  and  almost  always  fills  the  joint,  which  happens  less 
frequently  in  sprain.  An  extravasation  of  any  amount  at  both  malleoli 
should  always  suggest  fracture.  A  positive  diagnosis  is  only  possible, 
however,  by  careful  palpation  except  with  displacement;  by  following 
down  the  surface  of  the  bones  from  above  a  localized  point  of  tenderness 
is  found  at  the  site  of  fracture.  On  the  tibia,  in  the  absence  of  much 
swelling,  a  grooved  depression  can  be  felt  above  the  tip  of  the  malleolus, 
and  often  the  fragment  can  be  seized  and  shifted.  On  the  fibula  the 
upper  fragment,  pointed  and  projecting  somewhat,  can  sometimes  be 
felt.  Palpation  is  facilitated  by  pressing  the  extravasate  aside  gently; 
but  as  this  is  often  painful  it  may  be  impossible  without  anaesthesia.  If 
the  lower  fragment  is  not  too  large,  sometimes  it  can  be  rocked  under 
the  fingers  upon  the  edge  of  the  astragalus.  In  many  instances  crepitus 
and  false  motion  can  be  elicited  by  lateral  movements  of  the  fragment 
unless  the  manipulation  is  too  painful  or  hindered  by  swelling.  In  the 
latter  case  the  diagnosis  depends  upon  the  localized  point  of  tenderness; 
hence  the  importance  of  knowing  the  typical  lines  of  fracture. 

Hiiter  has  called  attention  to  the  pain  produced  by  flexing  the  foot 
forcibly,  due  to  the  fragments  being  wedged  apart  by  the  broader  front 
part  of  the  astragalus.  E.  Rotter  showed  that  pain  could  be  elicited  at 
the  point  of  fracture  by  pressing  the  tibia  and  fibula  together  higher  up. 

Wagstaffe  (1875)  and  Le  Fort  (1886)  described  a  peculiar  form  of 

fracture  of  the  external  malleolus,  a  tear-fracture,  produced  by  violent 

adduction  or  abduction  of  the  foot,  in  which  a  vertical  plate  wras  torn 

from  the  anterior  surface  of  the  external  malleolus  by  the  anterior  tibio- 

Vol.  III.— 47 


738  INJURIES  OF  THE  ANKLE  AND  FOOT. 

fibular  ligament.  It  is  apparently  more  common  than  was  formerly 
supposed.  (Ricard.)  The  extravasation  is  less  than  in  typical  fracture 
of  the  malleolus;  the  point  of  tenderness  corresponds  to  the  site  of 
fracture.     Pressing  the  tibia  and  fibula  together  is  painless. 

A  few  cases  are  reported  in  which,  in  addition  to  other  injuries  of  the 
tibia  and  fibula,  a  flat  plate  of  bone  was  broken  off  at  the  front  sur- 
face of  the  tibia  close  above  the  joint,  with  base  below  of  the  width  of 
the  tibia  and  tapering  upward  (Volkmann,  Lauenstein);  the  fragment 
was  apparently  broken  off  by  the  pressure  of  the  front  of  the  trochlea 
against  the  neck  of  the  astragalus  during  sudden  forcible  flexion  or 
inversion  of  the  foot  (Lauenstein). 

Separation  of  the  lower  epiphysis  of  the  tibia  occurs  up  to  the  twen- 
tieth year,  and  is  a  rather  frequent  injury  (compare  Figs.  458  and  459). 
It  may  be  complete  or  incomplete.  Displacement  is  often  very  slight. 
The  diagnosis  is  made  from  the  age  of  the  patient,  the  increased  breadth 
of  the  tibia,  pressure  tenderness  corresponding  to  the  epiphyseal  line,  and 
cartilaginous  crepitus.  The  treatment  consists  in  reducing  by  direct 
pressure  and  immobilizing  the  foot  as  in  malleolar  fracture. 

Diagnosis. — If  the  above  symptoms  are  properly  considered  the 
diagnosis  of  typical  malleolar  or  supramalleolar  fracture  is  always 
possible;  that  of  incomplete  fractures,  infraction,  lamellar  fractures, 
atypical  malleolar  or  supramalleolar  fractures,  is  more  difficult  and 
occasionally  impossible  even  under  ana?sthesia.  Infraction  and  lamel- 
lar fracture  can  usually  be  detected  with  the  .r-ray.  In  fact,  the  .r-ray 
is  of  inestimable  value  for  all  severe  atypical  fractures  if  two  views  are 
taken,  namely,  from  the  side  and  front,  to  prevent  deception. 

Treatment. — The  prognosis  depends  largely  upon  the  treatment.  If 
the  latter  is  appropriate,  even  severe  cases  may  recover  fully  without 
functional  disturbance.  From  more  recent  statistics  it  would  appear 
that  a  certain  amount  of  impairment  persists  in  about  one-fourth  of  the 
cases.  Reduction  is  effected  by  grasping  the  heel  and  dorsum  with  the 
hands  and  making  traction  upon  the  foot  while  the  leg  is  held  firmly. 
Any  lateral  or  forward  or  backward  displacement  is  then  determined 
by  comparing  with  the  other  foot.  The  position  of  the  front  part  of  the 
foot  is  of  less  importance  than  the  correction  of  any  lateral  displacement 
or  rotation  of  the  astragalus  and  calcaneum.  The  mistake  is  often 
made  in  an  eversion  fracture  with  outward  dislocation  of  the  tarsals  of 
inverting  the  foot  in  Chopart's  joint  without  correcting  the  inflexion  of 
the  malleoli  and  the  lateral  displacement  of  the  tarsals;  the  result  is  a 
pes  valgus.  Usually  the  foot  may  be  immobilized  in  its  normal  position, 
namely,  at  a  right  angle  to  the  axis  of  the  leg;  in  severe  cases  the 
proper  position  of  the  tarsals  and  the  malleolar  fragments  is  best  in- 
sured by  immobilizing  the  foot  in  slight  inversion. 

A  circular  plaster-splint  is  the  best  for  holding  the  reduced  foot  in 
position.  If  applied  immediately  after  the  injury,  it  should  be  well 
padded  to  avoid  the  dangers  contingent  upon  swelling.  It  should  be 
renewed  at  the  end  of  eight  or  ten  days  to  meet  the  looseness  resulting 
from  the  subsidence  of  the  swelling  and  flattening  of  the  padding.    Any 


FRACTURES  OF  THE  MALLEOLI. 


7.39 


intercurrent  displacement  should  also  be  overcome,  If  necessary  under 
anaesthesia.  In  mild  cases,  for  example  fractures  of  the  fibula,  the 
second  splint  may  be  worn  till  union  is  sufficiently  firm  to  allow  of 
massage  and  motion  in  the  joint  without  danger  of  producing  displace- 
ment, namely,  in  about  three  weeks.  Even  in  the  mildest  cases,  how- 
ever, the  patient  should  not  walk  after  this  without  wearing  a  supporting 
.splint  or  apparatus.  In  severe  cases  it  is  well  to  change  the  second 
splint  at  the  end  of  fourteen  days,  to  massage  and  move  the  foot  care- 
fully and  apply  a  new  splint  to  be  worn  for  about  three  weeks;  then 
massage  again,  and  passive  movements  of  the  joint.  The  splint  may 
be  removed  earlier,  but  should  be  reapplied  each  time,  after  massage. 
In  the  last  weeks  of  treatment  the  patient  may  go  about  on  crutches  but 
without  stepping  on  the  foot.  The  weight  should  not  be  placed  on  the 
foot  till  the  end  of  the  seventh  or  eighth  week  in  severe  cases,  as  the 

Fig.  464. 


Dupuytren's  splint  for  abduction  fractures  of  the  malleoli. 

callus  yields  readily  and  may  result  in  a  faulty  position  of  the  foot. 
The  older  and  heavier  the  patient,  the  later  and  more  cautiously  should 
the  foot  be  encumbered.  Too  early  use  is  often  responsible  for  a 
later  faulty  position  of  the  foot. 

Many  surgeons  disapprove  of  applying  the  plaster-splint  immediately 
after  injury  and  advise  immobilization  in  a  Volkmann  splint  for  the  first 
few  weeks.  This  is  quite  proper  if  the  foot  cannot  be  inspected  daily, 
but  if  it  is  under  constant  observation,  a  well-padded  plaster-splint 
is  unobjectionable  and  preferable,  as  it  insures  better  immobilization. 
Instead  of  this  strip  splints  may  be  used.  (Figs.  466  and  467.)  A 
simple  dressing  such  as  the  one  suggested  by  Dupuytren  for  abduction 
fracture  is  also  well  spoken  of  (Fig.  464);  it  may  be  valuable  in  an 
emergency,  but  it  is  not  advisable  for  longer  applicaton. 

Ambulant  treatment  with  the  so-called  portable  apparatus  has  been 
widely  recommended.     We  admit  that  the  experienced  are  in  a  position 


:40 


INJ CRIES  OF  THE  ANKLE  AND  FOOT. 


to  treat  slight  fractures  without  any  difficulty,  and  even  severe  fractures 
without  loss,  by  this  method.  But  in  general  the  surgeon  should  be 
warned  against  this  mode  of  treatment,  as  displacement  occurs  only  too 
easily  if  the  splint  does  not  fit  accurately  or  is  not  solid.  We  have  seen 
many  a  case  of  pes  valgus  produced  in  this  way.     Excellent  results  have 


Fig.  466. 


Fig.  407. 


Stimson's  outer  and  posterior  moulded  plaster-of-Paris  strip  splint?  for  fractures  about  the  ankle- 
joint;  applied  over. flannel  strips  (see  page  296;,  bandaged  with  light  gauze  roll  bandage,  the 
foot  held  by  hand  or  Band-bags  until  the  plaster  hardens,  gauze  bandage  then  removed,  adhesive- 
plaster  strips  applied  as  shown,  and  the  whole  bandaged  with  muslin  rolls.  Outer  strip  may 
extend  to  head  of  fibula,  if  desirable;  posterior  strip  should  not  encroach  upon  the  popliteal 
space  or  thigh  during  flexion.      (Solley.) 


also  been  obtained  by  means  of  various  extension  splints  and  apparatus, 
especially  by  Bardenheuer,  but  these  appliances  require  special  expe- 
rience and  care.  Bardenheuer  applies  broad  strips  of  heavy  adhesive 
plaster  (Segelfuchheftpflaster)  on  both  sides  of  the  leg  and  fastens  them 
together  under  the  sole  so  that  they  exert  pressure  against  the  malleoli. 


FRACT URES  OF  Til E  MALLEOLI.  7 4 1 

Outward  cross-traction  is  applied  above  the  malleoli  to  draw  the  bones 
of  the  leg  outward  and  overcome  the  pes  valgus.  The  pes  equinus 
position  and  backward  dislocation  of  the  fool  are  corrected  by  vertical 
extension  fastened  to  the  foot. 

In  conclusion,  the  chief  points  in  the  treatment  are  accurate  reduc- 
tion of  the  fragments,  absolute  control,  and  finally  improvement  of 
the  position  of  the  foot  after  the  swelling  of  the  joint  has  subsided. 
Upon  this  depends  largely  the  later  usefulness  of  the  limb.  Secondarily 
the  mobility  of  the  joint  has  to  he  thought  of.  Immobilization  should 
not  be  continued  too  long,  hut  massage  and  passive  motion  begun  as 
soon  as  the  danger  of  displacement  is  past.  The  weight  of  the  body 
should  not  be  placed  upon  the  toot  without  wearing  a  supporting  splint 
or  apparatus,  and  even  then  not  until  the  sixth  week;  in  severe  cases 
the  eighth  week.  Later,  massage,  especially  of  the  muscles  of  the  leg, 
and  exercises  are  very  important.  The  period  of  recovery  is  longer 
than  was  formerly  supposed.  In  the  mildest  cases — infraction  of  the 
fibula — the  patient  is  often  able  to  work  in  seven  or  eight  weeks.  Other- 
wise, in  mild  cases  light  work  is  usually  not  resumed  till  two  or  three 
months  and  heavy  work  in  about  five  months;  in  the  case  of  severe 
fractures  these  periods  become  three  to  four  and  four  to  eight  months, 
respectively,  or  even  longer.  The  long  duration  of  recovery  depends 
largely  upon  the  stiffness  and  painfulness  of  the  joint,  the  firm  oedema 
which  is  apt  to  occur,  and  the  weakness  of  the  muscles  of  the  leg  due  to 
the  long  fixation.  For  this  reason  great  care  should  be  exercised  in 
placing  the  full  weight  of  the  body  on  the  foot.  The  causes  of  per- 
manent damage  are  chiefly  faulty  position  of  the  fragments  and  of  the 
foot.  Especially  significant  in  this  respect  is  the  lateral  displacement 
and  rotation,  the  pes  valgus  position,  which  follows  eversion  fractures. 
This  can  be  prevented.  But  the  disturbances  due  to  deformation  of 
the  joint  following  comminuted  fractures,  or  marked  separation  of  the 
tibia  and  fibula  with  avulsion  of  fragments,  are  often  unavoidable. 

Some  of  the  articles  published  during  the  last  year  with  reference  to 
accident  legislation  fin  Germany)  give  valuable  information  in  regard 
to  what  has  been  and  what  can  be  accomplished  in  the  treatment  of 
malleolar  fractures.  Haenel  gives  the  statistics  of  -10  cases,  treated  by 
different  surgeons  and  under  partly  unfavorable  circumstances;  of 
these,  28  recovered  (70  per  cent.),  while  12  became  disabled  (30  per 
cent.);  the  average  loss  in  earning-efficiency  was  about  50  per  cent. 
These  extremely  unfavorable  results  are  hardly  what  anyone  would  have 
expected  at  the  time  of  this  compilation.  Incomparably  more  favorable 
are  the  results  reported  by  Jottkowitz  from  the  Knappschaftslazareth 
at  Konigshutte;  his  patients  were  under  treatment  from  the  first  to  the 
last  day  and  under  the  observation  of  a  physician  who  supervised  the 
medico-mechanical  as  well  as  the  purely  surgical  treatment  of  the  cases. 
Of  40  cases  of  malleolar  fracture  treated  under  these  conditions,  31 
(77  per  cent.)  recovered  fully  in  an  average  period  of  89.4  days,  and  a 
few  others  were  able  to  work  at  the  end  of  six  months.  The  average 
period  of  recovery  in  cases  of  fracture  of  both  malleoli  was  151.3  days; 


742  INJURIES  OF  THE  ANKLE  AND  FOOT. 

of  3  cases  of  this  sort,  1  was  discharged  cured,  1  with  20  to  30  per  cent, 
loss  in  earning-efficiency,  and  1  with  30  to  40  per  cent.  Of  15  cases  of 
fracture  of  the  lower  third  of  the  leg,  4  were  discharged  cured,  7  with 
20  to  30  per  cent.,  and  4  with  30  to  40  per  cent,  loss  in  earning-efficiency. 
The  results  obtained  by  Bardenheuer  in  the  Burgerspital  in  Cologne  by 
extension  treatment  are  almost  ideal  in  this  respect;  according  to 
Loew's  report,  all  of  the  patients  (68!)  with  simple  malleolar  fractures 
recovered  fully,  58  of  these  within  ninety-one  days.  Of  38  cases  of 
fracture  of  both  malleoli,  37  recovered  fully;  only  1  remained  disabled. 
Of  5  cases  of  supramalleolar  fracture,  all  recovered  fully  within  ninety- 
one  days.  These  results  are  good  evidence  of  the  value  of  the  extension 
method  and  especially  of  the  care  and  experience  of  the  attending 
surgeon,  upon  which  so  much  depends. 

The  question  of  operation  is  to  be  considered  in  exceptional  cases  in 
which,  in  spite  of  anaesthesia  having  been  used,  splinters  of  the  astrag- 
alus or  the  tibia  or  fibula  prevent  reduction  of  the  astragalus.  The 
question  arises  whether  it  is  advisable  to  be  satisfied  with  a  partial  result, 
or  whether  it  is  not  better  to  remove  the  splinters.  A  painful  and  more 
or  less  useless  foot  can  be  counted  upon  in  the  case  of  badly  reduced 
splinter  fractures,  so  that  active  interference  is  justified.  One  may 
expect  a  useful  and  movable  joint  if  the  interposed  fragments  can  be 
removed  without  injuring  the  malleoli  and  primary  union  be  secured. 
The  joint  can  be  opened  from  the  inner  side  and  the  foot  dislocated 
outward,  especially  if  the  fibula  is  broken;  in  some  instances  an  external 
incision  will  be  preferable,  and  in  compound  fractures  the  joint  can  be 
approached  through  the  wound. 

Union  with  deformity  can  be  but  little  influenced  by  means  of  cor- 
recting splints;  massage  and  long-continued  exercises  are  beneficial 
only  if  the  displacement  is  slight,  and  furthermore  call  for  great  energy 
and  perseverance  on  the  part  of  the  surgeon  and  patient.  If  there  is 
considerable  displacement,  the  conditions  grow  worse  from  month  to 
month,  so  that  it  is  useless  to  prolong  conservative  treatment.  The  earlier 
operation  is  performed,  therefore,  the  better  the  results.  Eversion  of  the 
foot — valgus  position — is  the  most  important  of  the  deformities  which  are 
left  after  improper  reduction  or  too  early  encumbrance  of  the  foot ;  it  is 
the  result  of  abduction  or  eversion  fractures,  the  most  frequent  of  all  frac- 
tures of  the  malleoli.  Pes  valgus  traumaticus  presents  a  typical  picture: 
the  foot  is  displaced  outward  and  everted,  the  inner  border  depressed, 
the  outer  elevated;  corresponding  to  the  original  dislocation,  the  foot  is 
also  frequently  displaced  backward  and  extended  (equinus  position). 
Above  the  joint  on  the  outer  side  there  is  an  angular  inflexion  of  the 
fibula;  the  internal  malleolus  is  greatly  thickened  by  callus.  In  severe 
cases  the  body-weight  cannot  be  supported  by  the  foot,  and  in  milder 
cases  only  with  great  pain.  The  axis  of  the  leg  which  passes  normally 
through  the  middle  of  the  sole  passes  through  or  to  the  inner  side  of 
the  inner  border  of  the  foot.  When  the  weight  is  thrown  upon  the  foot, 
it  is  twisted  further  outward;  the  resulting  laceration  of  the  tarsal  liga- 
ments causes  severe  pain;  deforming  inflammation  of  the  joints,  effusion 


FRACTURES  OF  THE  MALLEOLI.  743 

in  the  tendon-sheaths,  and  atrophy  of  the  muscles  of  the  leg,  add  to  the 
disturbance.  The  arch  of  the  foot  finally  gives  way  and  a  static  pes 
planus  with  all  its  disagreeable  consequences  develops  from  the  traumatic 
pes  valgus. 

The  treatment  of  traumatic  pes  valgus  is  by  one  of  three  methods:  (1 ) 
forcible  correction;  (2)  osteotomy;  or  (3)  resection.  Forcible  correc- 
tion gives  good  results  as  long  as  the  callus  is  soft  and  yielding — that  is 
in  the  first  six  weeks.  In  v.  Bergmann's  clinic  we  have  obtained  excellent 
results  in  this  manner,  giving  up  all  instrumentation  and  effecting  the 
correction  entirely  by  manipulation  with  gradually  increasing  pressure. 
If  used  carefully,  the  so-called  osteoclasts,  for  example,  of  Rizzoli, 
Collin,  and  others,  are  supposed  to  be  very  serviceable.  The  advantages 
of  subcutaneous  refracture  over  operation  for  oblique  fractures  with 
malunion  need  hardly  be  emphasized;  in  older  cases  with  firm  callus, 
however,  it  is  dangerous,  as  the  bone  is  very  liable  to  break  at  another 
point. 

For  such  cases  there  still  remains  the  open  method  of  osteotomy  and 
its  various  modifications.  In  mild  cases  transverse  division  of  the  fibula 
will  be  sufficient;  if  associated  with  fracture  of  the  internal  malleolus,  it 
will  be  necessary  in  addition  either  to  divide  the  adhesions  about  the 
internal  malleolus,  or  more  frequently  to  excise  a  wedge  from  the  tibia, 
as  the  internal  malleolus  often  prevents  reduction  on  account  of  its  dis- 
placement outward  or  the  excessive  callus  on  the  inner  side.  The 
operation  is  as  follows:  The  fibula  is  exposed  through  an  incision  on 
the  outer  side  of  the  leg  and  divided  squarely  across  with  the  chisel  after 
peeling  off  the  periosteum.  If  correction  is  still  impossible,  the  site  of 
fracture  on  the  tibia  is  exposed  through  a  second  longitudinal  incision, 
a  wedge  is  then  chiselled  out  at  the  site  of  fracture,  not  quite  through 
the  bone,  and  the  remaining  portion  fractured.  This  has  the  advantage 
of  preserving  the  periosteum  intact  on  the  outer  surface  of  the  tibia  and 
of  not  endangering  the  soft  parts  in  the  interosseous  space  by  chiselling. 
The  size  of  the  wedge  must  correspond  naturally  to  the  amount  of 
deviation.  An  existing  equinus  position  of  the  foot  is  overcome  by 
dividing  the  tendo  Achillis.  After  correction  has  been  accomplished, 
the  wTounds  are  closed  with  a  few  sutures,  a  sterile  dressing  is  applied  and 
the  foot  is  immobilized,  somewhat  overcorrected,  in  a  plaster-of-Paris 
splint.  Bone  sutures  are  usually  unnecessary.  We  have  repeatedly  ob- 
tained excellent  results  in  v.  Bergmann's  clinic  by  this  method.  Oblique 
osteotomy,  which  we  employ  only  for  marked  deviation,  has  the  advan- 
tage of  allowing  the  fragments  to  be  shifted  and  lengthened  upon  each 
other  without  being  separated,  although  Trendelenburg  has  shown  that 
good  union  results  even  after  simple  transverse  osteotomy  and  separa- 
tion of  the  surfaces.  Helferich  chisels  partly  through  the  tibia  and 
fibula  and  then  breaks  them  with  Rizzoli 's  osteoclast.  The  method  used 
in  France  during  the  decade  of  1890  of  resecting  a  large  piece  of  the 
lower  end  of  the  fibula  facilitated  the  correction  of  the  deformity,  but 
made  walking  impossible  without  supporting  apparatus,  so  that  it  has 
been  abandoned. 


744  INJURIES  OF  THE  ANKLE  AND  FOOT. 

To  correct  pes  varus  traumaticus,  the  traumatic  club-foot,  which  is 
usually  due  to  improperly  reduced  adduction  fractures,  the  fibula  is 
divided  transversely,  or  obliquely  from  above  downward  and  inward,  or 
a  small  wedge  is  removed,  and  if  then  the  foot  cannot  be  mobilized  the 
tibia  is  divided  transversely.  In  very  severe  cases,  especially  those  with 
splintering,  even  division  of  both  tibia  and  fibula  may  not  be  sufficient; 
it  will  then  be  necessary  to  enlarge  the  incision  on  the  inner  side  down- 
ward and  to  open  the  joint;  after  previously  dividing  the  fibula  it  is 
easy  to  dislocate  the  foot  outward,  remove  all  interposed  fragments  from 
the  astragalus  or  the  tibia  or  fibula  and  chisel  off  uneven  surfaces;  it  may 
be  necessary  to  resect  the  joint  partially.  The  malleoli  should  be  left  if 
possible  to  preserve  the  stability  of  the  joint.  Kirmisson  reports  good 
results  by  means  of  this  atypical  resection.  In  v.  Bergmann's  clinic 
we  have  not  been  compelled  thus  far  to  do  such  extensive  operations, 
and  should  reserve  them  for  desperate  cases. 

Pseudarthrosis  is  very  rare  and  is  usually  the  result  of  great  negligence. 
Its  treatment  corresponds  to  that  of  pseudarthrosis  in  general.  If  con- 
servative methods — a  portable  plaster-splint,  passive  congestion,  irritation 
of  the  fragments — are  ineffectual,  the  fragments  should  be  freshened  up 
and  sutured. 

FRACTURES  OF  THE  TARSUS. 

Fractures  of  the  Astragalus. — Fractures  of  the  astragalus  are  com- 
paratively rare.  In  1894  Gaupp  collected  60  cases,  but  it  is  certain  that 
the  injury  is  more  frequent  than  one  would  suppose  from  the  literature, 
for  Golebiewski  alone  saw  77  cases.  If  the  fracture  is  slight  it  is  difficult 
to  recognize;  it  has  been  mistaken  for  sprain,  fracture  of  the  malleoli, 
and  other  injuries,  and  occurring  with  fracture  of  the  malleoli  it  has 
been  overlooked.  Usually  it  is  produced  by  falling  from  a  height  upon 
the  feet,  the  bone  being  crushed  between  the  tibia  and  calcaneum,  less  fre- 
quently it  was  caused  by  forced  inversion  or  eversion  or  direct  violence, 
as  in  run-over  accidents,  etc.  Most  frequently  the  break  is  in  the 
least  resistant  part  of  the  bone,  namely,  the  neck,  the  fracture-line 
lying  as  a  rule  in  the  frontal  plane.  This  somewhat  typical  form  is 
produced  by  violent  flexion  of  the  foot,  the  front  margin  of  the  tibia 
thus  cutting  through  the  neck  of  the  astragalus;  a  fragment  is  usually 
broken  off  at  the  same  time  from  the  front  of  the  tibia.  (Konig.)  There 
may  be  little  or  no  displacement  of  the  fragments;  in  a  number  of  cases 
the  body  of  the  astragalus  was  displaced  backward  and  wedged  fast 
between  the  tibia  and  fibula  and  the  tendo  Achillis.  (Fig.  468.)  These 
cases  have  been  classed  improperly  with  dislocations  of   the  astragalus. 

Fracture  of  the  body  of  the  astragalus  is  more  rare.  The  bone 
may  be  broken  into  three  fragments:  an  anterior,  composed  of  the  neck 
and  head;  a  middle,  of  the  trochlea;  and  a  posterior,  of  the  posterior 
process:  or  it  may  be  divided  horizontally  into  an  upper  and  lower 
fragment:  or  obliquely  or  sagittally  into  two  lateral  fragments.  A  longi- 
tudinal and  transverse  fracture  may  be  combined  to  form  a  T-fracture. 


FRACTURES  OF  THE  TARSUS. 


745 


The  bone  may  be  crushed  or  comminuted.  Avulsion  or  loosening  of 
superficial  portions  of  cartilage  or  bone,  such  as  occasionally  happens 
as  a  complication  of  dislocation  of  the  astragalus,  are  of  slight  signifi- 
cance. In  a  relatively  large  percentage  of  cases  fracture  of  the  astragalus 
is  complicated  by  wounds  of  the  soft  parts  produced  by  displaced  frag- 
ments or  by  simultaneous  fractures  of  the  malleoli. 

Diagnosis. — The  diagnosis  of  fracture  of  the  astragalus  may  be  diffi- 
cult in  the  absence  of  any  displacement;  the  symptoms  are  then  those 
of  a  severe  sprain,  the  real  condition  sometimes  being  detected  only  after 
the  swelling  has  subsided  by  the  presence  of  callus  and  persistent  limita- 
tion of  motion  in  the  ankle-joint.  In  simple  sprain  the  swelling  and 
extravasation  of  blood  are  usually  not  so  marked;  in  fracture  of  the 
astragalus  the  tenderness  on  pressure  is  limited  chiefly  to  the  astragalus, 
and  the  attempt  to  bear  the  weight  on  the  foot  is  extremely  painful.     The 

Fig.  468. 


T 


! 


Fracture  of  the  astragalus.      (Kohlhardt.) 


intense  pain  also  produced  by  flexing  the  foot  is  characteristic;  crepitus 
may  be  elicited  at  the  same  time.  In  spite  of  careful  inspection  and 
palpation  the  diagnosis  is  not  always  possible;  in  doubtful  cases  the 
examination  should  be  continued  under  anaesthesia  and  with  the  a>ray. 
Even  in  these  cases  the  .r-ray  can  be  deceptive,  so  that  it  is  advisable 
always  to  obtain  skiagraphs  of  the  sound  foot  also,  if  possible,  for 
comparison. 

If  displacement  exists,  the  diagnosis  is  easier;  fragments  may  some- 
times be  felt  beneath  the  stretched  skin  at  abnormal  points  and  their 
contour  recognized  in  front  of  or  behind  the  malleoli.  In  fracture  of 
the  neck  the  foot  is  usually  extended  and  everted,  in  the  other  forms 
of  fracture  it  is  generally  flattened  or  in  the  valgus  position,  and  the 
malleoli  are  lower  than  usual.  Fracture  of  the  posterior  process,  in  the 
groove  of  which  runs  the  tendon  of  the  flexor  hallucis  longus,  occurs 
alone  or  in  connection  with  other  fractures,  and  is  denoted  by  thickening 


746  INJURIES  OF  THE  ANKLE  AND  FOOT. 

and    tenderness   behind   the   internal   malleolus   and   limitation  of  the 
movements  of  the  great  toe.     (Golebiewski.) 

Treatment. — In  the  absence  of  displacement  the  foot  can  be  immobilized 
at  a  right  angle  to  the  leg  for  three  or  four  weeks;  later,  massage  and 
passive  movements,  and  at  the  end  of  several  more  weeks  the  full  weight 
can  be  placed  on  the  foot.  If  the  fragments  are  displaced,  they  should 
be  reduced  by  traction  and  pressure  if  possible.  Otherwise  operation 
has  to  be  considered;  it  has  been  performed  successfully  among  others 
by  Sick.  If  the  fragments  cannot  be  coaptated  properly,  one  or  more 
of  them,  or  even  the  entire  astragalus,  may  have  to  be  removed  to  restore 
the  mobility  of  the  joint,  v.  Brims  was  compelled  in  one  case  to  remove 
the  astragalus  five  weeks  after  injury;  the  bone  was  extracted  through  an 
outer  incision  in  front  of  the  fibula;  the  result  was  ideal;  two  and  one-half 
years  later  there  was  no  difference  in  the  gait  in  the  two  feet.  In  com- 
pound fractures,  if  suppuration  occurs,  the  entire  bone  should  be  removed. 
Fracture  of  the  astragalus,  especially  with  any  great  amount  of  dis- 
placement, is  always  a  serious  injury.  In  many  cases  the  restoration  of 
function  is  complete,  but  in  others  the  mobility  of  the  foot  is  perma- 
nently impaired;  even  complete  ankylosis  may  develop  in  the  ankle-joint, 
and  the  lasting  disturbance  may  necessitate  extirpation  of  the  thickened 
bone  or  resection  of  the  joint  months  after  the  injury,  as  shown  by  v. 
Brims'  case.  The  earning-efficiency  is  impaired  from  15  to  20  per  cent, 
or  more,  an  average  of  30  per  cent. 

Fracture  of  the  Calcaneum.— Fractures  of  the  os  calcis  are  more 
typical  than  those  of  the  astragalus.  Although  until  recently  regarded 
as  a  rare  injury,  the  literature  of  fracture  of  the  calcaneum  has  been 
considerably  increased  since  the  enactment  of  accident  legislation  (Ger- 
many). According  to  Ehret,  fractures  of  the  os  calcis  constitute  2  per 
cent.,  and  according  to  Golebiewski  4  per  cent,  of  all  accident  cases. 
Compared  with  our  own  experience  these  figures  are  high.  An  accurate 
knowledge  of  fractures  of  the  calcaneum  is  indispensable  on  account  of 
the  severe  results  which  follow  non-recognition  or  improper  treatment 
of  the  injury.  Fractures  of  the  tuberosity  have  been  known  for  the 
longest  time.  They  are  usually  tear  fractures  produced  by  violent  con- 
traction of  the  muscles  of  the  calf.  It  is  generally  the  entire  portion  of 
bone  lying  behind  the  calcaneo-astragaloid  articulation  which  is  torn 
off,  exceptionally  the  point  of  attachment  of  the  tendo  Achillis.  (Plate 
XX.)  As  properly  emphasized  by  Gussenbauer,  the  fracture  is  not 
a  pure  tear-fracture,  but  is  the  result  of  two  component  forces,  the  trac- 
tion of  the  extensors  and  the  pressure  or  blow  due  to  the  weight  of  the 
body  in  falling.  The  fracture  is  commonly  the  result  of  falling  upon 
the  extended  foot.  The  fragment  is  drawn  upward  only  slightly  by  the 
tendo  Achillis,  as  it  is  held  by  the  plantar  fascia  and  the  plantar  muscles 
arising  from  the  calcaneum.  The  symptoms  are  clear:  inability  to  stand 
or  to  walk;  false  motion  and  displacement  of  the  tuberosity,  and  crepitus 
obtained  on  drawing  down  the  fragment. 

The  splint  should  be  put  on  with  the  knee  flexed  and  foot  extended  to 
the  utmost  and  with  adhesive-plaster  strips  applied  over  the  fragment  to 


FRACTURES  OF  THE  TARSUS.  747 

bind  it  down  in  place.  If  the  fragment  cannot  be  properly  reduced,  the 
functional  disturbance  is  usually  permanent;  the  patient  complains  of 
pain  in  the  sole  of  the  foot,  the  extensor  muscles  atrophy  and  hard  work 
is  impossible.  It  is  therefore  advisable,  if  the  fragment  cannot  be  held 
in  place  with  a  splint,  to  nail  it  in  place  through  the  skin,  as  recom- 
mended by  Gussenbauer.  If  greatly  displaced,  it  should  be  exposed 
and  sutured  in  position.  The  occurrence  of  pure  tear-fractures  of  the 
posterior  process  cannot  be  questioned.  As  seen  with  the  .r-ray,  they  are 
characterized  by  the  absence  of  all  symptoms  of  compression  (thicken- 
ing in  the  spongiosa,  irregular,  indistinct  outline);  the  line  of  fracture  is 
vertical. 

There  is  another  type  of  tear-fracture  in  which  a  thin  plate  of  bone  is 
torn  from  the  upper  surface  of  the  posterior  process  by  the  tendo  Achillis, 
the  line  of  fracture  being  horizontal,  parallel  to  the  lamellar  structure. 
(Helbing.)  (Fig.  469.)  If  the  fragment  is  much  displaced,  it  should 
be  sutured.     (Borchardt.) 

Fig.  469. 


Avulsion  fracture  of  a  horizontal  plate. 

Fractures  of  the  sustentaculum  tali,  of  the  inconstant  processus  infra- 
malleolaris,  and  of  the  tuber  calcis,  the  point  of  origin  of  the  short  muscles 
of  the  sole,  are  rare,  of  less  importance,  and  are  usually  associated  with 
other  fractures  of  the  calcaneum.  Isolated  fracture  of  the  sustentaculum 
tali,  which  naturally  produces  a  valgus  position  of  the  foot,  was  first  re- 
corded by  Abel.  It  may  entail  functional  impairment  of  the  flexor  com- 
munis digitorum  and  of  the  flexor  hallucis.  Ehret  saw  a  case  of  avulsion 
of  the  tuber  calcis,  thus  confirming  Golebiewski's  belief  of  its  occurrence; 
a  movable  fragment  is  felt  in  place  of  the  tuberosity.  Bidder  was  the 
first  to  observe  a  tear-fracture  of  the  processus  inframalleolaris;  he 
referred  it  to  the  tension  of  the  strong  calcaneofibular  ligament.  Whether 
this  explanation  is  correct  or  not,  is  still  an  open  question.  Golebiewski 
is  inclined  to  regard  the  fracture  as  due  to  direct  violence;  at  least  it  was 
so  in  his  own  case.  At  the  end  of  two  years  the  foot  was  still  consid- 
erably disabled  and  a  distinct  mass  of  callus  could  be  felt  about  the 
peroneal  tendons. 


748 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


The  fractures  by  compression  (par  ecrasement)  are  by  far  the  most 
important  of  the  fractures  of  the  calcaneum.  They  are  produced  usually 
by  falling  upon  the  feet,  exceptionally  by  direct  violence  applied  to  the 
heel.  In  the  former  case  the  more  solid  astragalus  is  forced  through 
the  softer  calcaneum  like  a  wedge.  (Ballenghien.)  These  compression 
fractures  are  usually  made  up  of  transverse  fractures,  the  greater  part  of 
which  generally  pass  through  the  sinus  tarsi,  and  of  longitudinal  frac- 
ture \s  running  more  or  less  horizontally  near  the  lower  surface;  there  is 
also  some  irregular  splintering.  (Fig.  470.)  The  severity  of  the  frac- 
ture depends  upon  the  distance  of  the  fall  and  the  weight  of  the  patient; 
if  both  components  are  slight,  the  fracture  and  the  displacement  may 
be  insignificant  or  absent;  if  the  force  is  very  great,  the  bone  may  be 
literally  crushed,  in  which  case  there  are  also  usually  fractures  of  the 

Fig.  470. 


Comminuted  fracture  of  the  calcaneum.    (Anger.) 


malleoli  or  astragalus.  The  part  of  the  calcaneum  chiefly  affected  by 
the  fracture  depends  upon  the  position  of  the  foot  at  the  time  of  injury. 
If  the  foot  strikes  the  ground  while  inverted,  it  is  the  inner  border,  sus- 
tentaculum and  neck,  which  are  affected  chiefly;  if  the  foot  is  everted, 
the  outer  margin  of  the  bone  is  injured;  if  the  foot  is  flexed,  it  is  mainly 
the  posterior  part,  and  if  extended,  it  is  the  anterior  part  which  suffers. 

Diagnosis. — The  difficulty  of  diagnosing  recent  fractures  of  the  cal- 
caneum is  shown  by  Ehret's  statistics  of  47  cases,  in  only  3  of  which  was 
a  correct  diagnosis  made  immediately  after  the  injury,  the  others  being 
regarded  as  fractures  of  the  malleoli  or  sprains.  The  reports  of  Baehr, 
Korte,  Golebiewski,  Thiem,  Sliwinski,  Helferich  and  others,  are  similar. 

Fissures  and  fractures  without  displacement  may  not  be  detected  on 
inspection  and  palpation;  the  symptoms  may  be  so  slight  aside  from 


FRACTURES  OF  THE  TARSUS.  749 

the  effusion  that  the  fracture  is  overlooked;  sometimes  the  weight  can 
be  placed  on  the  calcaneum;  if  the  fragments  are  displaced,  the  heel  is 
broader;  the  localized  tenderness  is  characteristic  and  crepitus  may  be 
felt  at  the  same  time;  movement  of  the  ankle-joint  is  fairly  free,  but  is 
very  painful  if  forced.  The  foot  is  usually  in  the  valgus  position  and 
appears  flattened;  the  malleoli  are  nearer  the  sole  of  the  foot;  in  a  few 
cases  the  foot  was  in  the  varus  position.  In  every  case  of  injury  due  to 
falling  from  any  considerable  height,  even  if  other  lesions  are  present, 
the  calcaneum  and  astragalus  should  be  examined  for  fracture.  Finally 
an  examination  under  anaesthesia  and  with  the  x-ray  if  necessary  will 
aid  the  diagnosis. 

Course. — The  subsequent  course  of  fractures  of  the  calcaneum  is 
rather  peculiar  and  characteristic.  In  the  mild  cases  without  deformity 
and  with  only  slight  subjective  symptoms  which  were  regarded  and 
treated  as  sprains,  the  first  attempts  to  walk  at  about  the  end  of  the 

Fig.  471. 


Fracture  of  the  anterior  process  of  the  calcaneum  from  an  z-ray.    (v.  Bergmann's  clinic.) 

second  week  caused  considerable  pain  on  account  of  the  irritation  of  the 
callus.  This  unusual  pain  should  always  incite  one  to  make  a  careful 
investigation,  and  the  case  should  alwavs  be  treated  as  a  fracture  if 
doubt  exists.  The  long  duration  of  recovery  is  almost  pathognomonic, 
especially  in  cases  with  displacement;  complete  recovery  has  thus  far 
been  an  exception.  In  Ehret's  47  cases  there  were  only  5  complete 
recoveries;  in  the  others  considerable  functional  disturbance  persisted, 
the  pain  in  the  sole  of  the  foot  and  in  the  calf  when  walking  compromising 
the  earning-efficiency  of  the  patient  for  years  or  even  permanently.  As 
long  as  a  cane  is  necessary  in  getting  about  an  indemnity  on  a  50  to  60 
per  cent,  basis  is  not  too  high.     (See  Accident  and  Judgment.) 

Aside  from  the  long-continued  subjective  discomfort,  the  gait  is  not 
infrequently  characteristic;  the  patient  avoids  placing  any  weight  upon 
the  heel,  and  therefore  walks  more  on  the  outer  or  on  the  inner  border 
of  the  foot,  according  to  the  site  of  fracture.  There  is  also  an  evident 
broadening  of  the  heel,  shown  clearly  by  charcoal  impressions  of  the 


750 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


feet,  which  is  referable  to  callus  production  in  the  crushed  bone;  the 
broadening  not  infrequently  corresponds  to  a  decrease  in  the  vertical 
diameter  and  as  a  result  to  a  lowering  of  the  malleoli.  The  grooves  at 
the  sides  of  the  tendo  Achillis  are  often  obliterated.  (Fig.  472.)  As  it 
is  usually  the  outer  part  of  the  bone  which  is  crushed  the  most,  the 
thickening  under  the  external  malleolus  is  more  pronounced.  This 
thickening,  as  emphasized  properly  by  Thiem,  is  often  mistaken  for  the 
callus  of  fractures  of  the  malleoli.  A  flat-foot  usually  develops  with 
some  inversion ;  if  the  patient  walks  on  the  outer  border  of  the  foot,  an 
actual  club-foot  can  develop.  Pes  valgus  does  not  occur  apparently 
unless  the  external  malleolus  is  fractured.  Motion  is  free  in  the  ankle- 
joint,  but  lastingly  impaired  in  the  calcaneo-astragaloid  and  calcaneo- 
cuboid joints — that  is,  eversion  and  inversion. 

Fig.  472. 


Old  fracture  of  the  calcaneum.     Left  normal  foot.     Right  foot  with  fracture  of  the  calcaneum; 
note  broadening  of  heel  and  obliteration  of  the  hollows  at  both  sides  of  the  tendo  Achillis. 


Treatment. — Compression  fractures  without  displacement  only  require 
that  the  limb  be  immobilized  in  a  T-  or  plaster-splint;  those  with  displace- 
ment demand  that  the  fragments  be  replaced  under  anaesthesia  and  a 
plaster-splint  applied.  Union  takes  place  very  slowly,  as  stated,  so  that 
walking  should  not  be  allowed  too  early,  not  before  the  ninth  week; 
later  a  long  course  of  baths,  massage,  and  passive  motion  is  likely  to  be 
necessary. 

Fractures  of  the  Small  Tarsal  Bones. — The  small  bones  of  the 
tarsus  are  rarely  fractured  save  by  severe  direct  violence,  so  that  as  a 
rule  the  fractures  are  comminuted  and  compound  and  associated  with 


DISLOCATIONS  OF  THE  FOOT.  751 

extensive  laceration  and  contusion  of  the  soft  parts.  'Flic  significance 
of  the  injury  therefore  depends  upon  threatened  infection.  Fracture  by 
indirect  violence  is  very  rare,  and  in  the  absence  of  displacement  is 
recognizable  only  by  eliciting  crepitus,  or  with  the  zc-ray. 

Treatment.— The  foot  should  he  immobilized  for  three  or  four  weeks. 
Recovery  usually  takes  place  without  any  functional  disturbance. 
Fracture  of  the  scaphoid  by  indirect  violence  has  recently  been  reported 
by  Kohlhardt. 

DISLOCATIONS  OF  THE  FOOT. 

By  dislocation  of  the  foot  is  understood  displacement  of  the  foot  in 
the  tibiotarsal  joint,  the  relation  of  the  astragalus  to  the  malleoli  being 
changed,  that  of  the  malleoli  to  each  other  unchanged.  The  dislocation 
may  be  lateral,  or  forward,  or  backward.  In  addition  to  these  two 
main  types,  namely,  lateral  and  sagittal,  one  speaks  of  an  upward  disloca- 
tion when  the  astragalus  is  forced  up  between  the  tibia  and  fibula. 
According  to  the  modern  generally  accepted  view  of  dislocation,  the 
distal  bone  is  the  one  dislocated,  in  this  case  the  astragalus;  so  the  older 
classifications  of  Malgaigne  and  Cooper,  which  spoke  of  dislocation  of  the 
tibia,  no  longer  apply.  The  direction  of  the  dislocation  is  determined 
by  the  relation  of  the  dislocated,  therefore  distal,  bone  to  the  proximal 
bone,  so  that  there  is  no  question  as  to  what  is  meant  by  forward  or  back- 
ward dislocation  of  the  foot.  It  is  different  with  lateral  dislocations: 
some  authors  (Konig,  Bardeleben)  designate  a  fibular  displacement  of 
the  foot  as  inward  dislocation  of  the  foot  because  the  trochlea  of  the 
astragalus  is  turned  toward  the  internal  malleolus.  Others  (Lossen, 
Hoffa,  Fischer,  Wendel)  designate  a  fibular  displacement  of  the  foot  as 
an  outward  dislocation,  which  is  more  in  accord  with  the  natural  rela- 
tions. Although  the  principle  of  the  Bardeleben-Konig  designation  is 
the  more  correct  one,  still  it  seems  less  involved  to  us  to  name  the  dislo- 
cation from  the  position  of  the  foot  as  a  unit  recognizable  from  without, 
rather  than  from  the  position  of  the  astragalus,  which  cannot  always 
be  determined  readily  by  palpation.  Furthermore,  Lossen  emphasizes 
the  fact  that  the  position  of  the  astragalus  is  not  constant,  that  in  addition 
to  being  rotated  on  its  sagittal  axis,  it  is  displaced  in  the  direction  in 
which  the  foot  is  dislocated ;  so  it  may  be  present  at  the  outer  side  of  the 
fibula  in  outward  dislocation,  hence  it  would  be  necessary  to  have 
different  terms  for  one  and  the  same  dislocation  of  the  foot  according 
to  the  position  of  the  astragalus.  Taking  the  foot  as  a  unit,  we  therefore 
designate  (with  Lossen,  Hoffa,  G.  Fischer,  Stetter,  Wendel)  fibular 
displacement  of  the  foot  as  dislocation  outward,  and  tibial  displacement 
as  dislocation  inward.  All  dislocations  of  the  foot  are  liable  to  be 
complicated  by  fractures,  especially  of  the  malleoli;  this  applies  particu- 
larly to  lateral  dislocations,  which  in  the  greater  majority  of  cases  occur 
secondarily,  namely,  after  the  malleolus  has  been  broken  off.  The  latter 
dislocations  have  therefore  been  designated  after  the  example  of  Stro- 
meyer  as  dislocation  fractures  or  fracture  dislocations.     (Fischer.)     In 


752 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


spite  of  the  frequency  of  this  combination  of  dislocation  with  malleolar 
fracture,  Wendel  has  recently  collected  10S  cases  of  uncomplicated 
dislocations  of  the  foot. 


Lateral  Dislocations  of  the  Foot.1 

Outward  Dislocations. — Outward  dislocations  are  produced  by 
violent  rotation  of  the  foot  outward  about  a  sagittal  axis — that  is,  eversion 
(eversion  dislocation);  or  by  rotation  about  a  vertical  axis,  namely, 
outward  rotation  of  the  tip  of  the  foot  (rotation  or  abduction  disloca- 
tion). The  astragalus  being  so  firmly  mortised  in  the  fork  of  the 
malleoli  always  causes  the  malleoli  to  be  broken  in  eversion  dislocation, 
and  generally  in  the  form  of  the  typical  eversion  fracture  (Pott's  fracture). 

Symptoms.  —  The  symptoms  of  the  usual  form  of  outward  dislocation 
are  the  same  as  those  of  eversion  fracture,  except  that  the  foot  is  even 
more  everted,  so  that  the  dorsum  faces  inward,  the  sole  outward  (Fig. 
473);  the  outer  border  of  the  foot  faces  upward,  the  inner  downward. 

Fig.  473 


Outward  dislocation  of  the  foot.     (Anger.) 

The  astragalus  may  lie  beneath  the  internal  malleolus,  or  obliquely 
between  the  separated  malleoli;  or  it  may  be  displaced  so  far  outward 
that  it  lies  under  the  external  malleolus  or  at  the  outer  side  of  the  fibula. 
The  internal  malleolus  may  perforate  the  soft  parts  at  the  inner  side 
of  the  joint.  An  uncomplicated  outward  dislocation  should  be  without 
symptoms  of  fracture;  but  this  happens  so  rarely  that  many  surgeons 
question  its  occurrence.  This  view  is  incorrect,  however,  as  Wendel 
found  19  uncomplicated  outward  dislocations  among  10S  cases. 

The  so-called  rotation  dislocations  (G.  Fischer)  or,  better,  abduction 
dislocations  are  frequently  accompanied  by  abduction  fractures. 
According  to  Henke,  the  mechanism  is  as  follows:  As  the  foot  is  twisted 
outward  the  inner  lateral  surface  of  the  astragalus  is  drawn  away  from 

1  Spath  divided  lateral  dislocations  into  outward  and  inward  dislocation-by-rotation;  to  be 
more  accurate,  he  added  the  terms  horizontal  and  vertical  according  as  the  foot  was  rotated 
about  a  horizontal  or  vertical  axis.  The  author's  dislocation  by  eversion  (pronation)  is  therefore 
equivalent  to  Spiith's  dislocation  outward  by  horizontal  rotation. 


DISLOCATIONS  OF  THE  FOOT. 


753 


the  articular  surface  of  the  internal  malleolus.  If  the  force  continues, 
the  malleolus  slips  behind  the  posterior  part  of  the  trochlea  and  the 
outer  margin  of  the  trochlea  presses  the  fibula  backward.  As  a  rule 
the  fibula  breaks  just  above  the  malleolus.  In  the  living  subject  the 
foot  is  usually  fixed  while  the  body  rotates  toward  the  other  side.  The 
case  combined  with  fracture  of  the  fibula  recently  seen  in  the  Berlin 
surgical  clinic  resembles  the  cases  of  Fischer  and  others  and  is  charac- 
teristic.    (Fig.  474.)     Wickhoff  gives  a  very  plausible  explanation  for 

Fig.  474. 


Abduction  dislocation  of  right  foot  with  fracture  of  fibula,     (v.  Bergmann.) 

the  rare  cases  of  dislocation  without  fracture  of  the  fibula;  his  idea  is 
that  the  fibula  may  not  break  if  there  is  sufficient  rotary  mobility  in  the 
upper  tibiofibular  joint,  and  the  fibula  is  flexible  enough  to  be  twisted 
to  the  given  angle  of  abduction.  Wendel  collected  8  cases  of  uncom- 
plicated abduction  dislocation  from  the  literature. 

The  most  prominent  symptom  is  the  abduction  of  the  foot  through 
90  degrees,  so  that  it  points  directly  outward,  the  inner  border  facing 
forward,  the  outer  backward;  at  the  same  time  it  is  slightly  extended. 
The  astragalus  is  wedged  between  the  malleoli,  which  are  separated; 
the  tibia  projects  forward  beneath  the  skin;  the  fibula  can  be  felt  behind. 
Vol.  III.— 48 


754  IX JURIES  OF  THE  ANKLE  AND  FOOT. 

If  there  is  a  simultaneous  abduction  fracture  the  wedging  of  the  astraga- 
lus between  the  malleoli  is  less  firm;  the  point  of  fracture  is  easily  found 
above  the  malleolus  on  the  fibula;  as  a  result  of  the  fracture  the  foot 
is  slightly  everted. 

Treatment. — The  reduction  of  eversion  and  abduction  dislocations  is 
best  effected  by  extending  the  foot  and  flexing  the  knee  to  relax  the 
tendo  Achillis,  and  then  making  downward  traction  upon  the  foot  and 
adducting  or  inverting  for  both)  with  direct  pressure  upon  the  tibia  and 
fibula. 

Inward  Dislocations. — Inward  dislocations  are  best  divided  into  two 
groups,  namely,  those  by  inversion  or  supination,  and  those  by  adduction 
or  inward  rotation  of  the  tip  of  the  foot. 

Fig.  475. 


*-***-- 


Dislocation  of  the  foot  by  inversion,     (v.  Brans.) 

Dislocation  by  inversion  is  produced  by  violent  rotation  of  the  foot 
about  a  sagittal  axis,  the  same  force  usually  producing  an  inversion 
fracture  without  much  displacement.  As  great  violence  is  required  to 
dislocate  the  foot,  the  injury  is  often  combined  with  multiple  fractures 
of  the  astragalus,  calcaneum,  tibia,  and  fibula,  and  with  wounds  of  the 
joint.  Whereas  dislocation  inward  combined  with  fracture  is  rather  less 
frequent  than  the  corresponding  dislocation  outward,  uncomplicated 
inward  dislocations  are  much  more  frequent  than  the  corresponding 
outward  variety.  As  emphasized  by  "YYendel,  this  may  be  due  in  part 
to  the  shortness  of  the  internal  malleolus,  which  is  less  exposed  to 
pressure  in  inversion  of  the  foot,  but  it  is  due  more  to  the  greater  strength 
of  the  malleolus;  the  greater  power  of  resistance  of  the  internal  malleolus 
was  noticed  by  Honigschmied,  who  could  produce  fracture  of  the 
internal  malleolus  in  only  one  instance  by  violent  inversion  in  18  experi- 


DISLOCATIONS  OF  THE  FOOT.  755 

ments  on  the  cadaver.    There  are  only  36  uncomplicated  dislocations 

by  inversion  known  in  literature. 

Symptoms. — The  symptoms  are  as  follows  (Fin;.  47o):  The  loot  is 
inverted  as  in  club-foot,  the  inner  border  is  elevated,  the  sole  faces 
inward.  The  foot  may  he  rotated  !)()  degrees  on  its  long  axis;  the  trochlea 
of  the  astragalus  faces  outward  and  lies  beneath  the  external  malleolus. 
Wounds  of  the  joint  are  common,  and  are  chiefly  due  to  the  fibula 
perforating  outward. 

Dislocation  by  adduction,  produced  by  violent  inward  rotation  of  the 
foot  about  its  vertical  axis  is  extremely  rare;  Wendel  collected  3  cases. 
The  foot  points  inward,  the  outer  border  facing  forward,  the  inner 
backward;  the  astragalus  may  lie  behind  the  tibia  and  fibula  under  the 
internal  malleolus,  or  at  the  inner  side  of  the  tibia. 

Treatment. — The  reduction  of  inward  dislocation  is  easy  as  a  rule  by 
flexing  the  knee,  making  traction  on  the  foot,  and  increasing  the  patho- 
logical position,  then  everting  or  abducting  (or  both)  with  direct  pressure 
upon  the  tibia  and  fibula. 

Sagittal  Dislocations  of  the  Foot. 

Backward  Dislocations. — According  to  Henke  and  Honigschmied's 
experiments,  backward  dislocations  can  be  produced  by  forced  extension 
of  the  foot.  In  the  living  subject  it  occurs  in  the  same  manner  by  falling 
backward  with  the  foot  fixed  or  by  falling  upon  a  surface  which  inclines 
forward.  The  posterior  articular  margin  of  the  tibia  forms  a  fulcrum 
against  the  trochlea,  by  the  action  of  which  the  capsule  is  torn  in  front, 
and  the  force  continuing  drives  the  tibia  forward  over  the  trochlea  and 
through  the  tear  in  the  capsule.  The  tibia  then  becomes  fixed  if  the 
foot  is  flexed  again  to  a  right  angle.  Extensive  laceration  of  the  capsule 
and  ligaments  is  essential  for  the  production  of  the  dislocation.  The 
dislocation  may  be  complete  or  incomplete.  In  the  majority  of  cases 
the  fibula  is  broken,  the  upper  fragment  being  displaced  forward  with 
the  tibia,  the  lower  backward  with  the  astragalus.  Occasionally  the 
internal  malleolus  is  torn  off.  The  skin  is  frequently  perforated.  Figs. 
476  and  477  are  from  a  case  produced  by  a  fall  in  the  typical  manner 
with  the  foot  extended.  The  foot  was  firmly  fixed  in  the  pathological 
position;  a  fracture  of  the  fibula,  which  was  not  palpable,  was  shown 
by  the  a>ray  taken  laterally  but  not  sagittally.  This  shows  the  neces- 
sity of  making  two  exposures  and  also  the  possibility  that  the  number 
of  WendePs  uncomplicated  dislocations  would  have  been  decreased  by 
examination  with  the  a*-ray. 

Symptoms. — The  symptoms  are  very  characteristic;  the  front  of  the 
foot  is  shortened  and  the  heel  correspondingly  lengthened;  the  tibia 
projects  on  the  dorsum  of  the  foot,  the  sharp  edge  of  its  articular  surface 
being  felt  beneath  the  tense  skin.  In  a  thin  foot  one  can  sometimes 
see  that  the  extensor  tendons  are  more  tense  and  prominent  than  usual 
on  the  dorsum.  Behind,  the  tendo  Achillis  curves  downward  and  back- 
ward to  the  tuberosity  of  the  caleaneum  and  there  is  a  deep  furrow  in 


756 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


front  of  it  on  either  side.  The  foot  is  usually  fixed;  in  a  few  cases  it 
can  be  extended  or  flexed  slightly. 

Treatment. — Reduction  is  by  forced  extension,  then  forward  traction 
on  the  foot  with  counterpressure  on  the  leg,  and  then  flexion. 

Forward  Dislocations. — Uncomplicated  dislocation  forward  is  less 
common  than  the  corresponding  backward  variety;  according  to  Wendel, 

Fig.  476. 


Backward  dislocation  of  the  foot.      (v.  Bergmann.) 

Fig.  477. 


A'-ray  of  Fig.  476. 


11  to  26.  The  dislocation  is  produced  by  forced  flexion  of  the  foot. 
The  front  articular  margin  of  the  tibia  impinges  against  the  depression 
on  the  astragalus  in  front  of  the  trochlea;  the  capsule  is  thus  torn  open 
behind,  and  if  the  force  then  drives  the  foot  forward  or  the  leg  back- 
ward, the  trochlea  is  pushed  forward  on  the  tibia  and  fibula,  the  tibia 
becoming  fixed  in  the  depression  behind  the  trochlea  as  soon  as  the  foot 
is  extended  to  a  right  angle.  The  dislocation  may  be  complete  or 
incomplete. 


Disi.iKATlnss  OF  THE  FOOT. 


757 


Symptoms. — The  fool  appears  to  be  lengthened  (Fig.  478);  the  heel 
is  less  prominent;  the  tendo  Achillis  runs  directly  downward;  the 
malleoli  arc  depressed;  the  trochlea  can  be  fell  in  front.    The  foot  is 

sometimes  everted  or  inverted  and  may  be  slightly  flexed  or  extended. 

Diagnosis. — As  in  posterior  dislocation,  the  diagnosis  is  usually  simple, 
except  where  the  dislocation  is  incomplete  or  there  is  mueh  swelling; 
in  either  ease  it  may  be  mistaken  for  malleolar  or  supramalleolar  frac- 
ture. 

Treatment. — Reduction  is  by  extreme  flexion  and  backward  pressure 
on  the  foot  with  counterpressure,  followed  by  extension. 

Fig.  478. 


Forward  dislocation  of  the  foot.     (Anger.) 

Upward  Dislocations. — Only  5  uncomplicated  cases  of  this  sort  have 
been  published,  aside  from  a  few  associated  with  fracture  of  the  tibia 
or  fibula.  The  dislocation  is  produced  by  falling  upon  the  foot  or 
upon  the  heel;  the  foot  is  thus  driven  upward  between  the  tibia  and 
fibula;  the  foot  appears  shortened  because  the  astragalus  is  wedged 
between  the  tibia  and  fibula;  the  malleoli  are  depressed. 

Treatment. — Reduction  is  apparently  easy  by  making  traction  on  the 
foot. 


Perforation  of  the  skin  is  not  an  uncommon  occurrence,  as  stated,  in 
all  dislocations  of  the  foot.  One  or  both  malleoli  may  perforate  at  the 
time  of  injury  or  later,  following  necrosis  of  the  skin  due  to  pressure  of 
the  bones.  If  the  perforation  is  recent,  the  dislocation  is  reduced  after 
carefully  preparing  the  limb  and  inserting  drains  of  iodoform  gauze  in 
the  wound.     If  reduction  is  difficult,  the  wound  should  be  enlarged; 


758  INJURIES  OF  THE  ANKLE  AXD  FOOT. 

if  still  impossible,  part  of  the  projecting  bone  is  excised;  the  latter  applies 
also  if  the  bone  is  soiled.  If  suppuration  occurs,  resection — usually 
only  partial — is  necessary.  It  generally  gives  good  functional  results 
ami  makes  amputation  unnecessary  as  a  rule. 

The  after-treatment  of  dislocations  of  the  foot  demands  great  care; 
even  the  dislocations  unaccompanied  by  fracture  require  immobilization 
for  from  four  to  six  weeks  on  account  of  the  extensive  laceration  of  the 
ligaments.     Fractures  require  their  appropriate  treatment. 

Old  dislocations  usually  interfere  greatly  with  locomotion.  This 
applies  especially  to  the  backward  variety,  after  which  the  foot  remains 
in  the  equinus  position.  The  talipes  calcaneus  position,  which  is  apt 
to  develop  after  non-reduction  of  a  forward  dislocation,  is  somewhat 
less  disabling.  Old  dislocations  can  apparently  be  reduced  after  some 
length  of  time;  Hiiter  reduced  a  forward  dislocation  at  the  end  of  six 
months.  If  reduction  is  impossible  even  after  dividing  the  tendo  Achillis, 
operation,  with  division  of  the  angularly  united  fracture  or  resection 
of  the  joint,  is  indicated. 


DISLOCATION  OF  THE   TARSAL  BONES. 

Of  the  dislocations  of  the  astragalus,  we  distinguish  subastragaloid 
dislocation,  the  ankle-joint  being  intact,  and  total  dislocation,  in  which 
the  bone  is  torn  from  all  its  attachments,  as  described  by  Broca  in  1S53. 
Previous  to  this  date  the  dislocations  of  the  astragalus  in  the  tibiotarsal 
and  mediotarsal  joints  had  all  been  classified  together  as  dislocations 
of  the  astragalus. 

Subastragaloid  Dislocation. — This  form  is  very  rare,  being  produced 
only  by  great  violence  acting  more  or  less  directly  upon  the  mediotarsal 
joint  and  tearing  the  strong  ligaments  in  the  sinus  tarsi.  We  owe 
our  knowledge  of  the  mechanism  to  Broca  and  Henke.  The  foot,  the 
dislocated  part,  may  be  displaced  inward,  outward,  backward,  or 
forward,  the  two  former  varieties  being  most  frequent,  the  latter,  the 
forward  variety,  being  very  rare. 

Dislocation  Inward. — By  forced  inversion  and  adduction  of  the  foot, 
as  in  falling  upon  the  outer  edge  of  the  foot,  the  posterior  border  of  the 
sustentaculum  becomes  a  fulcrum,  the  astragalus  and  calcaneum  are 
forced  apart  at  the  outer  side,  the  head  of  the  astragalus  becomes  disar- 
ticulated from  the  scaphoid,  the  interosseous  ligament  between  them  is 
torn,  and  the  astragalus  is  pushed  forward  by  the  weight  of  the  leg  over 
the  calcaneum;  it  may  impinge  against  the  front  of  the  latter  or  even 
slip  beyond  it  outward  over  the  articular  facet.     (Lossen,  Henke.) 

The  foot  is  adducted  and  inverted  as  in  talipes  varus  (Figs.  479  and 
480);  the  inner  border  appears  concave  and  shortened,  the  outer  convex 
and  lengthened.  The  external  malleolus  is  more  prominent  and  the  cal- 
caneum is  absent  below  it;  in  front,  the  head  of  the  astragalus  can  be 
seen  and  felt  lying  upon  the  front  of  the  calcaneum  or  upon  the  cuboid. 
The  prominence  of  the  internal  malleolus  is  effaced;  below  it  can  be 


lUsLOCATloy  OF  THE  TARSAL  BONES. 


759 


distinctly  fell  the  inner  border  of  the  calcaneum  and  the  sustentaculum. 
Further  in  front  one  can  feel  the  scaphoid  projecting  abnormally.  Active 
motion  is  lost,  passively  the  fool  ran  be  flexed,  extended,  and  inverted 
in  the  tibiotarsal  joint,  l>nt  not  everted,  the  latter  being  pathognomonic 
in  case  the  swelling  prevents  palpation. 


Fig.  -17«J. 


Kir..  -ISO. 


Subastragaloid  dislocation  inward.     (Anger.)  Subastragaloid  dislocation  inward.     (Hoffa.") 

Dislocation  Outward. — This  is  produced  by  forced  eversion,  as  in  falling 
heavily  with  the  foot  turned  outward  or  by  a  blow  against  the  outer  side  of 
the  leg  while  the  foot  is  fixed.  The  fulcrum  is  the  upper  anterior  surface 
of  the  calcaneum;  the  joint  between  the  astragalus  and  calcaneum  gapes 
at  the  inner  side,  the  interosseous  ligament  between  the  two  bones  is 
torn,  and  the  astragalus  slips  inward  over  the  articular  facets  of  the 
calcaneum  and  over  the  scaphoid  while  the  foot  is  everted.  The  pos- 
terior facet  of  the  astragalus  lies  upon  the  sustentaculum  and  the  head 
lies  above  and  to  the  inner  side  of  the  scaphoid;  if  the  force  continues, 
the  astragalus  and  calcaneum  may  become  so  separated  that  the  foot 
lies  entirely  to  the  outer  side  of  the  external  malleolus. 

The  position  of  the  foot  is  like  that  of  a  high-grade  pes  planus. 
(Figs.  481  and  482.)  The  calcaneum  and  cuboid  project  abnormally 
at  the  outer  border  of  the  foot,  and  above  them  there  is  a  depression  at 
the  site  of  the  external  malleolus  and  head  of  the  astragalus.  The 
internal  malleolus  is  less  prominent  than  usual;  in  front  of  it  the  head 


760 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


of  the  astragalus  projects  excessively  beneath  the  skin.  Below  and  in 
front  of  the  latter  on  the  dorsum  can  be  felt  the  scaphoid,  behind  which 
the  soft  parts  can  be  indented  slightly.  Flexion  and  extension  are 
possible  in  the  tibiotarsal  joint,  but  eversion,  and  especially  inversion, 
are  limited.  The  external  malleolus  is  commonly  broken  off  by  the 
pressure  of  the  calcaneum. 


Fig.  482. 


Subastragaloid  dislocation  outward.    (Anger.) 


Subastragaloid  dislocation  outward.     (Hoffa.> 


Dislocations  Backward  and  Forward. — The  very  rare  sagittal  disloca- 
tions of  the  astragalus  are  produced  by  forced  extension  or  flexion;  by 
extension  the  astragalus  is  levered  off  against  the  posterior  surface  of 
the  facets  of  the  calcaneum,  and  by  flexion  against  the  anterior  surface 
of  the  same;  it  is  pressed  forward  by  the  tibia  over  the  scaphoid,  or 
backward  upon  the  posterior  part  of  the  calcaneum.  So  the  backward 
variety  of  subastragaloid  dislocation  is  produced  by  hyperextension 
(Fig.  483)  and  the  forward  variety  by  hyperflexion  (Fig.  484).  Only 
a  few  cases  have  been  reported  of  these  two  forms. 

Hildebrand  distinguishes  two  types  of  backward  dislocation,  in  one 
the  head  of  the  astragalus  points  forward,  in  the  other  downward  with 
its  articular  surface  resting  upon  the  upper  surface  of  the  scaphoid 
and  cuboid,  so  that  its  long  axis  represents  a  prolongation  of  the  axis 
of  the  tibia.  In  the  second  type  the  head  of  the  astragalus  is  missing 
on  the  dorsum,  the  distance  between  the  scaphoid  and  cuboid  is  greater,. 


DISLOCATION  OF  THE  TARSAL  BONES. 


761 


and  aversion  and  inversion  of  the  foot  arc  freer  than  in  the  first  type. 
Quenu  reports  a  ease  in  which  on  section  the  head  of  the  astragalus 
lay  upon  the  calcaneocuboid  joint.  This  was  a  transition  form  between 
backward  and  inward  dislocation;  the  foot  was  fixed  in  the  varus  position; 
the  length  of  the  heel  was  increased;  motion  in  the  ankle-joint  normal. 
Quenu  classifies  backward,  inward,  and  backward  and  inward  disloca- 
tions as  variations  of  the  same  dislocation,  which  he  terms  dorsal  dislo- 
cation, the  common  characteristic  of  which  is  the  position  of  the  head 
of  the  astragalus  upon  the  dorsum  to  the  outer  side  of  the  tendon  of 
the  tibialis  anticus.  He  accordingly  divides  subastragaloid  dislocations 
into  dorsal,  outward,  and  forward  dislocation,  a  classification  commonly 
used  in  France.  Burnett  and  Kaufmann  report  a  case  each  in  which 
the  scaphoid,  astragalus,  and  malleoli  were  in  their  normal  relation, 


Fig.  483. 


Fig.  484. 


Subastragaloid  dislocation  backward.     (Hoffa.) 


Subastragaloid  dislocation  forward.     (Hoffa). 


while  the  rest  of  the  foot  was  dislocated  backward  and  inward  in  Bur- 
nett's case,  and  backward  and  outward  in  Kaufmann's.     (Fig.  485.) 

In  forward  and  backward  subastragaloid  dislocations  the  foot  is 
apparently  lengthened  or  shortened  similarly  as  in  tibiotarsal  dislo- 
cations, but  differs  from  the  latter  in  that  flexion  and  extension  are 
preserved  in  the  tibiotarsal  joint.  Formerly  reduction  was  frequently 
unsuccessful,  chiefly  because  the  mechanism  was  not  known.  But  even 
to-day  it  can  be  prevented  by  interposition  of  capsule,  ligaments,  muscles, 
or  fragments  of  bone.  The  lateral  dislocations  are  reduced  best  by 
flexing  the  knee  fully,  increasing  the  pathological  position,  extending 
the  foot  strongly,  and  then  carrying  it  over  into  the  opposite  position. 
The  sagittal  dislocations  are  reduced  in  the  same  manner  with  the  knee 
flexed  and  the  foot  extended  or  flexed  as  demanded,  and  if  necessary 
by  direct  pressure  upon  the  astragalus  or  also  upon  the  scaphoid.     If 


762  INJURIES  OF  THE  ANKLE  AND  FOOT. 

reduction  is  impossible  or  was  previously  neglected,  operation  is  indi- 
cated, and  if  still  unsuccessful,  the  head  or  the  entire  astragalus  should 
be  removed. 

Total  Dislocation  of  the  Astragalus. — Total  dislocation — the  double 
dislocation  of  the  astragalus  of  Boyer  and  Malgaigne — is  a  combination 
of  tibiotarsal  and  mediotarsal  dislocation  of  the  astragalus,  and  exists 
if  the  astragalus  is  torn  from  all  its  articular  connections.  This  very 
rare  injury  is  more  frequent  than  subastragaloid  dislocation,  yet  only  50 
cases  are  known,  and  Kronlein  did  not  see  a  single  instance  among 
400  dislocations.  Four  types  are  distinguishable  practically:  forward, 
backward,  outward,  and  inward.  In  addition  to  these,  many  variations 
and  combinations,  especially  of  lateral  and  sagittal  dislocations,  occur, 
also  complete  reversal  of  the  astragalus  about  its  vertical  or  long 
(horizontal  I  axis.  Complete  reversal  is  seen  chiefly  in  connection  with 
other  dislocations. 

Fig.  485. 


Subscaphoid  dislocation.     (Kaufmann.) 

The  mechanism  is  very  complicated,  and  in  spite  of  long  study  sur- 
geons are  agreed  only  on  the  fact  that  lateral  dislocations  are  produced 
essentially  by  great  violence  acting  upon  an  everted  or  inverted  foot. 
Rognetta  assumed  from  experiments  that  forward  dislocation  was  pro- 
duced by  forced  extension  of  the  foot  while  the  leg  was  pressed  backward. 
Experimentally  Dauve  produced  forward  and  outward  dislocation  by 
extension  and  inversion,  and  forward  and  inward  dislocation  by  exten- 
sion and  eversion.  Henke  demonstrated  just  the  opposite.  After 
dividing  all  the  ligaments,  or  after  dislocating  the  astragalus  in  the 
tibiotarsal  and  then  in  the  mediotarsal  joint,  and  reducing  these  dislo- 
cations, if  the  foot  were  flexed,  a  forcible  jerk  of  the  tibia  produced 
forward  dislocation  of  the  astragalus,  and  backward  dislocation  if  the 
foot  were  extended.  Therefore  Henke  assumed  that  anterior  disloca- 
tion of  the  astragalus  was  produced  by  hyperflexion  and  simultaneous 
eversion  or  inversion,  and  posterior  dislocation  by  hyperextension  with 
inversion  or  eversion. 

Both  theories  have  their  defendants:  Phillips  and  others  side  with 
Rognetta  and  Dauve,  Lossen  with  Henke,  and  cases  substantiating  both 
theories  have  been  seen. 


DISLOCATION  OF  THE  TARSAL  BONES. 


763 


Stetter  claimed  that  forward  dislocation  could  be  produced  by  either 
forced  flexion  or  extension,  the  essential  being  previous  excessive  eversion 
or  inversion.  This  was  supported  by  the  findings  of  various  operations 
for  dislocation  of  the  astragalus.  (Loebker.)  Riedinger  and  Middel- 
dorpf  describe  specimens  of  forward  and  outward  dislocation  in  which, 
in  addition  to  a  fracture  on  the  inner  side  of  the  astragalus  evidently 
due  to  forced  eversion,  there  was  a  wedge-shaped  fracture  with  apex 
forward  of  the  back  of  the  trochlea,  evidently  due  to  forced  extension. 
Two  similar  cases  were  reported  by  Middeldorpf.  Schlatter  demon- 
strated that  with  the  foot  slightly  extended  severe  lateral  violence  alone 
could  produce  anterior  dislocation.    That  the  rare  backward  dislocation 


Fig.  486. 


Fig.  487. 


Forward  and  outward  dislocations  of  the 
astragalus.     (Anger.) 


Inward  dislocation  of  the  astragalus. 
(Anger.) 


is  evidently  produced  by  forced  extension  of  the  everted  or  inverted  foot 
is  corroborated  by  the  experiments  of  Heinecke  and  Dorsch  made  in 
L889. 

Diagnosis. — The  diagnosis  of  total  dislocations  of  the  astragalus  is 
usually  easy  except  in  the  presence  of  much  swelling,  when  anaesthesia 
will  be  required.  In  inward  dislocation  the  foot  is  everted,  abducted, 
and  slightly  extended.  (Fig.  4S7.)  [?]  In  outward  dislocation  the  foot  is 
adducted  and  inverted;  it  may  be  inverted  so  that  the  sole  faces  directly 
inward;  the  astragalus  projects  prominently  beneath  the  skin  on  the 
dorsum,  to  the  inner  or  outer  side  of  the  middle  line,  according  as  the 
dislocation  is  forward  and  inward  or  forward  and  outward;  the  bone 
may  perforate  the  skin.     In  forward  dislocation  the  foot  is  extended 


764  INJURIES  OF  THE  ANKLE  AND  FOOT. 

and  the  malleoli  are  nearer  the  ground ;  the  foot  is  apparently  lengthened 
and  the  astragalus  can  be  felt  beneath  the  skin  in  front.  In  backward 
dislocation  the  foot  appears  shortened;  the  astragalus  is  felt  behind 
between  the  tibia  and  tendo  Achillis,  nearer  either  the  outer  or  inner 
malleolus.  In  front  a  depression  replaces  the  normal  resistance  of  the 
astragalus. 

Total  reversal  of  the  astragalus  about  its  horizontal  or  vertical  axis 
is  very  difficult  to  recognize.  In  Seiler's  case  of  rotation  about  the  long 
axis  the  foot  was  displaced  outward,  the  toes  were  flexed;  active  and 
passive  motion  in  the  tibiotarsal  joint  was  impossible.  On  the  inner 
side  of  the  foot  below  the  malleolus,  the  head,  posterior  part  of  the  body, 
and  between  them  the  convex  lower  articular  surface  of  the  astragalus 
could  be  distinguished.  (Fig.  488.)  On  operation  a  fracture  of  the 
internal  malleolus  and  of  the  sustentaculum  were  also  found. 


Fig.  488. 


Internal  malleolus. 
Posterior  portion  of 
body  of  astragalus. 


Total  dislocation  of  the  astragalus  with  rotation  about  its  long  axis.     (Seller.") 

These  total  reversals  of  the  astragalus  are  only  explained  by  a  rotating 
force  acting  on  the  dislocated  bone;  whether  it  is  transmitted  from  the 
tibia  or  due  to  muscular  action,  or  whether  the  rotation  is  caused  by 
the  action  of  two  opposing  forces,  is  still  unknown.  The  condition  has 
not  been  produced  experimentally.  The  dislocation  is  frequently  com- 
plicated by  perforation  of  the  skin  by  the  head  of  the  astragalus.  In 
some  instances  there  was  also  a  fracture  of  the  astragalus,  fragments  of 
the  bone  being  torn  off  by  the  ligaments,  or  the  posterior  part  of  the 
bone  was  compressed,  or  the  head  was  separated  from  the  body  at  the 
neck. 

Treatment. — Reduction  is  best  accomplished,  with  the  knee  and  hip 
flexed  to  relax  the  muscles,  by  making  downward  traction  on  the  foot 
while  the  pathological  position  is  increased,  and  then  by  direct  pressure 
on  the  astragalus.  Dislocations  complicated  by  wounds  of  the  soft 
parts  should  be  treated  on  general  principles;  the  wound  should  be 
drained  with  strips  of  iodoform  gauze.     According  to  the  available 


DISLOCATION  OF  THE  TARSAL  BONES. 


705 


statistics,  reduction  has  been  successful  in  only  one-fourth  of  the  cases. 
If  the  dislocation  remains  unreduced  the  function  is  usually  bad,  the 
skin  is  apt  to  undergo  pressure  necrosis,  the  astragalus  becomes  necrotic, 
and  suppuration  with  all  its  serious  consequences  follows.  Excision  of 
the  astragalus  has  therefore  been  recommended,  especially  by  Xelaton, 
and  employed  by  most  surgeons.  Since  the  introduction  of  antisepsis, 
Hamilton  (1884)  has  reported  11  cases  in  which  operation  and  reduction 
were  successful,  but  in  3  of  these  the  astragalus  had  to  be  removed  later. 
Operative  reduction  should  always  be  attempted  unless  the  asepsis  of 
the  wound  is  questionable;  the  wound  should  be  enlarged  appropriately 
and  drained  with  iodoform  gauze.  Soiled  splinters  of  bone  are  excised. 
If  suppuration  occurs,  the  astragalus  is  removed;  even  then  the  function 
is  fairly  good,  as  the  malleoli  fit  over  the  calcaneum  and  the  foot 
is  fairly  movable  with  only  a  slight  tendency  to  an  equinus  position, 
v.  Bergmann's  success  in  operating  in  1892  for  simple  non-reducible  dis- 
locations has  led  him  to  recommend  operation  for  all  cases  not  reducible 
under  anaesthesia.  The  suggestion  has  been  followed  since  then  by 
several  surgeons.  As  the  callus,  in  the  case  of  fractures,  was  found  to 
impair  the  function  of  the  ankle-joint,  the  fragment  has  been  extracted, 
but  the  advantage  of  such  partial  resection  over  complete  removal  of 
the  bone  has  not  been  definitely  settled. 

Dislocation  of  the  Calcaneum. — Lossen  reports  a  few  cases  of  out- 
ward dislocation  of  the  calcaneum.  In  Dumas'  2  cases  the  outer  and 
upper  surface  of  the  calcaneum  was 
felt  below  the  external  malleolus, 
which  was  deep  in  the  soft  parts;  the 
front  of  the  calcaneum  formed  a 
distinct  prominence  above  the  cuboid. 
The  astragalus  was  in  its  normal 
relation  to  the  scaphoid  and  tibia; 
below  it  the  normal  resistance  of  the 
calcaneum  was  absent.  Reduction 
was  by  inward  pressure  upon  the  cal- 
caneum and  counterpressure  upon 
the  leg. 

Dislocation  in  the  Mediotarsal 
or  Chopart's  Joint. — Although   dis- 
puted  by  many  surgeons,  especially 
on  the  authority  of  Broca  and  Henke, 
the  occurrence  of  dislocation  in  Cho- 
part's joint  cannot  be  doubted  at  the 
present  time.      It    has  been  demon- 
strated   in    2  cases  of  Thomas   and 
Anger.    In  these  the  head  of  the  astra- 
galus and  the  anterior  articular  surface  of  the  calcaneum  projected  dis- 
tinctly beneath  the  skin  above  the  second  row  of  tarsals.    Fuhr's  recent 
investigations  corroborate  the  observations  of  Petit,  Bell,  Cooper,  and 
Smith.     In  1  of  Fuhr's  2  cases  there  was  complete  inward  dislocation. 


Fig.  489. 


Inward  dislocation  of  the  foot  in  Chopart's 
joint.      (Fuhr.) 


766  IX JURIES  OF  THE  ANKLE  AXD  FOOT. 

(Fig.  489.)  The  patient,  twenty  years  old,  had  been  run  over  by  a  loco- 
mobile. The  left  foot  was  adducted  and  inverted  and  sharply  concave 
in  front  of  the  inner  malleolus.  The  head  of  the  astragalus  and  the  an- 
terior articular  surface  of  the  calcaneum  could  be  easily  recognized  under 
the  tense  skin  in  front  of  the  outer  malleolus.  Under  anaesthesia  the 
scaphoid,  concealed  by  extravasation,  could  be  felt  in  front  of  the  inner 
malleolus.  Reduction  was  easy  by  traction  on  the  foot  and  direct  pressure. 
In  the  other  case  the  dislocation  was  outward,  and  resulted  from  fall- 
ing backward  off  a  stepladder,  the  left  foot  being  caught  between  the 
two  lower  rungs  while  the  body  fell  to  the  left.  The  foot  was  slightly 
everted  and  abducted  and  broadened  in  front  of  the  malleoli;  the  head 
of  the  astragalus  was  felt  under  the  tense  skin  close  in  front  of  the  inner 
malleolus;  on  the  outer  side  of  the  foot  could  be  felt  the  articular  surface 
of  the  calcaneum  for  the  cuboid;  the  relation  of  the  calcaneum  to  the 
malleoli  was  normal.  Reduction  was  by  forced  abduction  in  Chopart's 
joint  with  the  calcaneum  fixed  and  with  pressure  upon  the  astragalus. 

The  dislocations  in  Chopart's  joint  are  very  similar  to  subastragaloid 
dislocations  except  that  the  normal  relation  of  the  astragalus  to  the  cal- 
caneum is  unchanged.  Dislocations  and  subluxations  of  the  calcaneo- 
cuboid, as  well  as  incomplete  dislocations  in  the  astragaloscaphoid  joint, 
have  also  been  reported. 

Dislocation  of  the  Small  Tarsals. — Dislocation  of  the  scaphoid 
alone  and  of  one  or  more  cuneiforms  with  their  metatarsals  has  been 
seen.  The  dislocation  was  usually  upward  from  direct  violence  or  by 
falling  upon  the  ball  of  the  foot  with  the  foot  extended.  For  reduction 
only  the  general  rule  can  be  given  to  increase  the  size  of  the  cavity  from 
which  the  bone  has  been  displaced.  This  will  usually  be  accomplished 
therefore  by  forcibly  extending  the  foot;  the  bones  are  then  reduced  by 
direct  pressure.  The  dislocations  of  the  small  tarsal  bones  are  so  mani- 
fold that  a  short  description  is  impossible.  (Compare  the  literature 
given  by  Baehr. )  In  the  case  of  old  dislocations  a  corresponding  cavity 
can  be  hollowed  out  in  the  shoe,  or,  if  very  troublesome,  the  joint  can  be 
resected  or  the  bone  excised. 

Complicated  and  Compound  Injuries  in  and  about  the  Ankle-joint. 
— The  occurrence  and  treatment  of  wounds  complicating  fractures  and 
dislocations  of  the  ankle-joint  and  tarsus  have  already  been  mentioned. 
The  cases  of  comminution  of  the  bones  of  the  leg  or  ankle  are  more 
serious.  Suppuration  easily  produces  necrosis  of  the  bones,  involve- 
ment of  one  or  more  joints,  and,  as  the  tendon-sheaths  are  usually 
opened  by  the  trauma,  rapid  transmission  of  the  infection  upward. 
The  severe  crushing  injuries,  due  to  direct  violence,  run-over  accidents, 
etc.,  are  even  more  serious  on  account  of  the  possibility  of  immediate 
gangrene  and  necrosis,  and  of  secondary  infection  from  the  rather  com- 
mon uncleanliness  of  the  skin  of  the  foot.  A  foudroyant  infection  can 
develop  very  readily  in  the  bruised  tissues  and  spread  rapidly  through 
the  bones,  opened  joints,  and  tendon-sheaths.  It  may  even  advance- 
rapidly  to  the  production  of  a  fatal  malignant  cedema.  The  unyielding- 
ligaments  and  fascia  interfere  seriouslv  with  free  drainage  and  favor 


DISLOCATION  OF  THE  TARSAL  BONES.  767 

suppuration.     Recovery  is  therefore  retarded  and  the  function  of  the 
parts  jeopardized  by  necrosis  of  the  bones  and  protracted  suppuration. 
Gunshot-wounds  of  the  fool  vary  greatly;  they  may  open  the  capsule 

of  the  ankle-joint  without  injuring  the  bone,  or  perforate  the  spongiosa 
of  the  tibia  without  involving  the  joint.  But  this  is  the  exception,  for  as 
a  rule  the  bones  and  joints  arc  both  involved.  If  the  trochlea  of  the 
astragalus  is  perforated,  nol  merely  grazed,  there  are  almost  always 
fissures  running  into  the  various  joints,  so  that  if  infection  occurs  the 
communicating  joints  arc  also  involved.  Gunshot-wounds  of  the 
tarsus  almost  always  affect  several  bones  and  joints,  or  involve  the  latter 
through  fissures.  The  amount  of  comminution  of  the  bones  varies 
naturally  according  to  the  character  and  penetrating  power  of  the  pro- 
jectile. The  more  severe  wounds  produced  by  hand  firearm-,  and 
especially  those  produced  by  heavy  ordnance,  are  very  similar  in  char- 
acter to  the  compound  fractures  by  crushing  mentioned  above,  and  are 
liable  to  be  badly  infected.      (Septic  Phlegmon.) 

Treatment. — Amputation  is  necessary  primarily  at  the  present  time 
only  in  the  severest  cases  of  extensive  comminution,  but  is  required 
more  often  secondarily  in  acute  septic  phlegmon  to  save  the  patient's 
life.  Small  recent  wounds  are  to  be  kept  aseptic  by  careful  cleansing 
and  sterilization  of  the  foot  and  application  of  a  simple  dressing.  If  the 
skin  is  undermined  or  endangered  by  the  tension  of  an  extravasation 
of  blood,  free  incisions  should  be  made  to  relieve  tension,  establish  an 
outlet  for  the  extravasate  and  discharge  from  the  wound  and  facilitate 
the  casting  off  of  gangrenous  sloughs.  The  incisions  should  be  kept  open 
and  the  cavities  drained  with  iodoform  gauze.  If  infection  has  already 
taken  place,  in  addition  to  free  incisions,  the  foot  should  be  immobilized 
and  elevated,  or  suspended  in  a  splint  extending  above  the  knee.  Or  a 
fenestrated  plaster-splint  may  be  applied  or  the  limb  placed  upon  a 
double  inclined  plane.  Whatever  splint  is  used,  the  fixation  of  the  foot 
at  a  right  angle  to  the  limb  is  very  important  in  case  ankylosis  should 
follow,  for  if  the  foot  becomes  ankylosed  in  any  other  position,  its  use- 
fulness is  seriously  or  even  completely  impaired. 

These  general  principles  of  conservative  treatment  are  applicable  to 
all  injuries,  including  most  of  the  gunshot-wounds.  In  field  service, 
particularly  in  anticipation  of  transportation,  the  first  dressing  should 
insure  proper  immobilization  of  the  limb,  even  if  the  cleansing  and 
sterilization  of  the  foot  have  to  be  incomplete  and  the  dressing  only 
provisional. 

Primary  resection  is  necessary  only  when  tire  soft  parts  are  severely 
injured,  and  then  merely  enough  bone  should  be  removed  to  insure  free 
drainage.  Secondarv  resection  is  usuallv  urgent  as  soon  as  infection 
occurs;  one  may  first  attempt  to  check  the  suppuration  by  free  drainage, 
but  in  view  of  the  unfavorable  anatomical  conditions,  resection  should 
not  be  delayed  too  long.  v.  Langenbeck's  experience  in  the  Schleswig- 
Holstein  War  of  1864  showed  that  even  extensive  resection  of  the  tibio- 
tarsal  joint  could  give  good  results.  The  formation  of  new  bone  fol- 
lowing resection  for  suppuration  is  very  abundant  and  usually  produces 


768  INJURIES  OF  THE  ANKLE  AND  FOOT. 

ankylosis.  The  after-treatment  is  very  important  in  order  to  prevent 
a  faulty  position  of  the  foot.  Huter  recommended  total  resection  as  a 
rule.  v.  Langenbeck  preferred  partial  resection  if  possible,  as  it  insured 
more  fully  the  usefulness  of  the  foot,  a  view  held  by  most  surgeons  at 
the  present  time.  The  extent  of  resection  is  determined  by  the  amount 
of  splintering,  the  necessity  for  free  drainage,  and  the  measures  required 
to  secure  a  good  position  of  the  foot.  If  only  the  lower  end  of  the  tibia 
and  fibula  are  involved,  the  astragalus  is  preserved  as  far  as  possible. 
If  the  astragalus  is  perforated,  and,  as  usual,  the  suppuration  involves 
the  calcaneo-astragaloid  joint,  it  should  be  removed.  Even  if  all  three 
bones  are  fractured  and  have  to  be  removed,  parts  of  the  malleoli 
should  be  preserved  if  possible  to  insure  the  stability  of  the  foot.  In 
regard  to  the  results  of  resection  of  the  ankle-joint  in  war  only  the 
statistics  of  the  preantiseptic  period  are  available.  Billroth  estimated  a 
mortality  of  about  35  per  cent.,  Grossheim  a  mortality  of  40  per  cent, 
for  total,  and  30  per  cent,  for  partial  resection. 

Suppuration  in  the  tarsus  following  injuries  is  even  less  influenced  by 
simple  incision  and  usually  requires  resection  of  several  bones.  The 
technic  will  be  discussed  later. 


INJURIES  OF  THE  METATARSUS  AND  TOES. 

Fractures  of  the  Metatarsals  and  Phalanges. — Fractures  of  the 
metatarsals  are  more  common  than  was  formerly  supposed.  They  are 
usually  due  to  direct  violence,  such  as  heavy  weights  falling  upon  the  foot, 
and  are  associated  with  extensive  wounds  of  the  soft  parts.  If  the  skin  is 
intact,  a  fracture  is  easily  overlooked  and  the  marked  extravasation  of 
blood  referred  to  contusion  until  at  the  end  of  several  weeks  the  persist- 
ent swelling  and  functional  disturbance  occasion  a  careful  examination 
and  callus  is  discovered.  In  recent  cases  accompanied  by  considerable 
swelling  a  positive  diagnosis  is  only  possible  under  anaesthesia  or  with 
the  .c-ray.  Especially  by  the  aid  of  the  latter  have  we  been  able  to 
recognize  the  cause  of  a  painful  and  formerly  misinterpreted  swelling  of 
the  foot,  called  tumor  of  the  foot  by  Breithaupt,  which  was  observed 
particularly  in  soldiers;  it  was  referred  to  an  inflammation  of  the  tendon- 
sheaths,  cf  the  deep  ligaments,  or  to  disease  of  the  tarsometatarsal  joints. 
With  the  x-tsly  Schulte,  Stechow,  and  Kirchner  found  that  it  was  almost 
always  due  to  a  fracture  of  a  metatarsal.  These  fractures  were  often 
produced  by  slight  violence,  for  example,  during  a  long  march  or  by 
jumping,  and  at  first  occasionally  produced  so  little  disturbance  that 
they  were  easily  overlooked.  In  the  majority  of  cases  they  were  incom- 
plete— "green-stick  fractures."  In  more  than  90  per  cent,  of  the  cases 
the  break  was  in  the  middle  third  of  the  second  or  third  metatarsal;  in 
a  few  instances  in  the  fourth  or  fifth,  and  thus  far  never  in  the  first. 
(Fig.  490.)  Although  by  no  means  a  rarity  in  civil  practice,  the  con- 
dition is  more  frequently  met  with  in  soldiers,  a  fact  upon  which  the 
weight  of  the  knapsack  has  unquestionably  some  bearing. 


1  S.I  TRIES  OF  THE  METATARSUS  AM)   TOES. 


7G9 


they  should   be 
for  from   two  to 

Fig.  490. 


Prognosis.—  The  prognosis  of  fractures  of  the  metatarsals  depends 
upon  the  severity  and  number  of  the  fractures.  Those  with  extensive 
lesions  of  the  soft  parts  always  entail  severe  functional  disturbance, 
although  the  simple  fractures  by  indirect  violence  are  liable  to  disable 
the  patient  for  months  or  even  permanently;  in  the  very  mild  eases  the 
period  of  recovery  is  from  four  to  six  weeks. 

Treatment.  —  If  the  fragments  are  much  displaced, 
corrected  by  manipulation  and  the  foot  immobilized 
three  weeks;  later  massage.  Walking  should 
not  be  permitted  too  soon,  not  before  the  fifth 
or  sixth  week,  the  same  as  in  all  fractures  of 
the  tarsals  and  ankle.  Simple  fractures  of 
the  phalanges  are  treated  in  the  same  way 
as  those  of  the  fingers. 

Dislocations  of  the  Metatarsals  and  the 
Phalanges. — Dislocation  in  the  tarsometa- 
tarsal joint,  Lisfranc's  joint,  is  very  rare. 
One  distinguishes  total  dislocation,  in  which 
all  the  metatarsals,  and  partial  dislocation, 
in  which  single  metatarsals  are  dislocated. 
In  1897  Panse  collected  22  total  and  23 
partial  dislocations  from  the  literature,  of 
the  former  the  dorsal  variety  being  most 
frequent. 

Total  Dislocation  of  the  Metatarsus. — Dis- 
location upward  has  been  produced  by  falling 
from  a  height  and  landing  upon  the  front  of 
the  foot,  by  falling  and  striking  upon  the 
extended  metatarsus,  by  a  heavy  weight 
falling  upon  the  tarsals,  by  which  the  same 
are  driven  downward  and  are  not  infre- 
quently fractured.  The  symptoms  are  very 
characteristic.  The  foot  appears  shortened, 
is  slightly  extended,  while  the  toes  are  flexed. 

The  arch  of  the  foot  is  increased.     Transversely  over  the  dorsum  pro- 
jects the  line  of  the  base  of  the  metacarpals. 

Dislocation  downward  was  seen  only  once  by  Smyly.  (Lossen.) 
The  mechanism  is  not  known,  but  it  is  probably  the  reverse  of  that  of 
upward  dislocation.  In  Smyly's  case  the  transverse  line  of  the  project- 
ing tarsals  could  be  felt,  and  in  front  of  it  a  deep  groove;  the  metatarsus 
projected  into  the  sole.  The  reduction  of  both  forms  is  by  traction  and 
direct  pressure. 

The  mechanism  of  lateral  dislocations  is  much  disputed  on  account  of 
the  projection  backward  of  the  base  of  the  second  metatarsal  beyond 
the  other  metatarsals  in  Lisfranc's  joint.  Malgaigne,  Hofta,  Lessen, 
and  others  assume  that  lateral  dislocation  is  possible  only  after  fracture 
or  upward  dislocation  of  the  second  metatarsal.  This  is  true  of  the 
majority  of  cases.  Dislocation  inward,  which  has  been  seen  only  once 
Vol.  III.— 49 


Fracture  of  the  second  metatarsal. 
(v.  Bergmann.) 


770 


INJURIES  OF  THE  ANKLE  AND  FOOT. 


Fig.  491. 


(Kirk),  is  hardly  conceivable  without  previous  fracture  of  the  second 
metatarsal.  The  possibility  of  outward  dislocation  can  be  understood 
from  the  obliquity  of  the  sides  of  the  second  and  third  cuneiforms; 
Pan  e  admitted  tins  possibility.  At  any  rate,  fracture  of  the  second 
metatarsal  has  been  found  in  only  half  of  the  cases.  Dislocation  outward 
was  usually  produced  by  outward  pressure  upon  the  inner  border  of  the 
front  part  of  the  foot  while  the  heel  was  fixed,  less  frequently  by  violent 
adduction  of  the  heel  with  the  front  of  the  foot  fixed.  Quenu  regarded 
it  as  an  outward  rotation-dislocation,  as  he  was  able  to  produce  it  by 
forced  extension  of  the  front  of  the  foot  with  inward  rotation  of  and 
inward  pressure  upon  the  back  of  the  foot. 

Diagnosis. — Lateral  dislocations  in  Lisfranc's  joint  are  easily  recog- 
nized. If  dislocated  outward,  the  front  of  the  foot  is  usually  slightly 
abducted;  the  first  cuneiform  projects  at  the  inner  side  of  the  foot,  the 

base  of  the  fifth  metatarsal  on  the  outer 
side.  (Fig.  491.)  If  dislocated  inward, 
the  first  metatarsal  projects  at  the  inner 
side,  and  at  the  outer  side  is  a  depression 
in  front  of  the  cuboid. 

Prognosis. — The  prognosis  is  good  if 
the  dislocation  is  recognized  and  reduced 
in  proper  time. 

Treatment. — Reduction  of  lateral  dis- 
locations is  best  effected  by  fixing  the 
tarsus,  increasing  the  dislocation  by  trac- 
tion and  corresponding  ab-  or  adduction 
and  then  adducting  with  lateral  pressure 
for  dislocation  inward,  and  the  reverse  for 
dislocation  outward.  The  foot  should  be 
immobilized  for  from  two  to  three  weeks. 
Dislocation  of  Single  Metatarsals. — 
Dislocation  of  one  or  more  metatarsals 
is  generally  upward,  rarely  downward. 
The  first  and  fifth  can  also  be  displaced 
outward  or  inward. 

Treatment. — Reduction  is  by  traction 
on  the  dislocated  bone  and  pressure  upon 
the  projecting  part.  If  unsuccessful,  the  joint  is  exposed,  and  if  the 
bone  cannot  be  replaced  the  end  should  be  removed.  The  same  applies 
to  old  dislocations.  Even  in  case  of  non-reduction  the  foot  becomes 
fairly  useful. 

Dislocation  of  the  Phalanges. — Dislocation  of  the  toes  in  the  meta- 
tarsophalangeal joints  is  rare;  that  of  the  hallux  is  most  frequent  and 
important. 

Upward  dislocation  of  the  great  toe  is  the  most  common  of  the  various 
forms,  and  is  produced  by  extreme  flexion;  the  head  of  the  metatarsal 
is  forced  downward,  tears  the  capsule,  and  slips  out  while  the  base  of 
the  phalanx  slips  over  it.     This  presupposes  great  violence.     The  dis- 


Complete  outward  dislocation  in    Lis- 
franc's joint.     (Panse.) 


Tx.jrniijs  of  Tin-:  metatarsus  and  toes. 


771 


location  is  commonly  received  in  jumping.  The  first  phalanx  lies 
Hexed  upon  the  head  of  the  metatarsal;  the  second  phalanx  is  extended. 
The  dislocation  may  be  complete  or  incomplete;  the  head  of  the  meta- 
tarsal frequently  perforates  the  skin  on  the  under  surface.  The  hin- 
drances to  reduction  are  the  same  as  in  the  corresponding  dislocation 
of  the  thumb.  (Bartholmai.)  Reduction  is  by  increasing  the  flexion 
and  then  pressing  the  phalanx  forward  so  that  its  base  will  push  aside 
the  interposed  parts.  Operative  reduction  is  necessary  for  irreducible 
or  old  dislocations,  eventually  possibly  resection.  Even  if  unreduced, 
they  give  little  trouble  if  a  suitable  shoe  is  worn. 

Dislocations  of  the  hallux  outward  and  upward,  of  which  single 
instances  have  been  reported,  are  apparently  only  variations  of  the 
above.  Dislocation  inward  is  produced  by  abduction  of  the  toe.  (Mal- 
gaigne,  Notta.)  In  the  few  cases  reported  reduction  was  simple  by 
traction  and  direct  pressure. 

Fig.  492. 


Backward  dislocation  of  the  hallux.     (Anger.) 


Dislocations  of  the  four  outer  toes  are  commonly  upward,  and  are 
entirely  analogous  to  the  corresponding  dislocation  of  the  great  toe;  one 
or  more  or  even  all  five  (Pailloux)  have  been  dislocated.  Josse  reports 
a  case  of  outward  dislocation  of  all  five  by  a  fall  from  a  horse.  The 
very  rare  interphalangeal  dislocations  correspond  to  those  of  the  fingers; 
they  are  more  frequent  in  the  great  toe  than  in  the  others,  and  are  com- 
monly upward.  Hardly  a  dozen  cases  of  dislocation  of  the  terminal 
phalanx  of  the  great  toe  are  known  and  even  fewer  of  interphalangeal 
dislocation  of  the  other  toes.  (Broca,  Riedinger,  Styx.)  From  experi- 
ments, Riedinger  assumes  that  upward  interphalangeal  dislocation  of 
the  four  outer  toes  is  only  possible  after  lateral  dislocation,  and  not  by 
hyperextension  alone. 

Reduction  is  by  traction,  with  the  aid  of  a  slip-noose  if  necessary,  and 
by  pressure. 

Complicated  Injuries  of  the  Metatarsus  and  Toes. — The  principles 
of  treatment  given  for  injuries  of  the  tarsus  are  equally  applicable  to 
complicated  injuries  of  the  metatarsus  and  toes. 

The  methods  used  at  present  in  the  treatment  of  wounds  permit  us  to 
go  very  far  in  preserving  injured  parts.  With  reference  to  the  foot,  this 
conservatism  can  be  carried  too  far,  however.     ^Ye  should  bear  in  mind 


772  INJURIES  OF  THE  ANKLE  AND  FOOT. 

that  the  loss  of  a  toe  (except  the  great  toe,  see  chapter  on  Operations  on 
the  Foot)  is  of  little  or  no  importance,  while  primary  amputation  or 
exarticulation  of  a  toe  is  of  greater  advantage  to  the  patient  than  a  poor 
stump  saved  at  the  expense  of  a  long  period  of  confinement.  The  same 
applies  to  severe  complicated  injuries  of  the  metatarsus.  Transverse 
amputation  through  the  metatarsals  gives  excellent  results,  so  that  it  is 
frequently  preferable  to  conservative  treatment. 

Good  functional  results  require  that  the  operation  should  be  in  sound 
tissues;  the  ends  of  the  bones  should  be  well  padded  with  flaps  of 
healthy  tissues  so  constructed  that  the  suture-line  avoids  the  sole  of 
the  foot.  The  amputation  is  made  squarely  across  and  covered  in  with 
two  flaps,  a  large  plantar  and  small  dorsal,  or  one  large  plantar  flap. 


CHAPTER  XXXVIII. 

DISEASES  OF  THE  ANKLE  AND  FOOT. 

ACUTE  AND  CHRONIC  INFLAMMATIONS  OF  THE  OUTER 
SOFT  PARTS. 

Acute  Inflammations. — Acute  inflammations  are  less  common  and 
less  important  in  the  foot  than  in  the  hand.  Furuncle  and  carbuncle 
are  rare  and  confined  mostly  to  the  dorsum  of  the  foot  and  toes.  Small 
ulcers,  sometimes  very  painful,  occur  between  the  toes  of  people  whose  feet 
perspire  and  who  wear  tight  shoes.  This  is  also  the  favorite  spot  of  other 
ulcerations,  such  as  the  papular  syphilide,  chancroid,  and  carcinoma. 
Small  abscesses  frequently  develop  under  the  epidermis  ("subepider- 
moidal"),  chiefly  at  points  of  pressure  and  in  blisters  or  after  slight 
wounds;  occurring  under  thick  callosities  on  the  sole  or  under  corns  they 
can  be  very  painful.  The  local  swelling  may  be  very  slight,  but  associated 
with  considerable  oedema  on  the  dorsum  of  the  foot.  The  suppuration 
under  callosities,  etc.,  may  spread  beneath  the  skin  into  a  diffuse  cellu- 
litis. Usually,  however,  the  process  is  in  the  reverse  direction;  a  sub- 
cutaneous suppuration  due  to  irritation  or  slight  wounds  perforates 
outward;  sometimes  the  pus  then  spreads  under  the  epidermis  on  the 
sole  of  the  foot;  the  deep  and  superficial  abscesses  thus  formed  com- 
municate through  a  small  opening  in  the  cutis,  and  are  comparable  in 
form  to  a  shirt-stud.  On  the  dorsum  such  subcutaneous  suppuration 
often  follows  a  lymphangitis.  If  the  process  is  in  the  sole  of  the  foot, 
incision  should  be  made  early,  as  it  can  spread  more  easily  beneath  the 
aponeurosis  than  it  can  perforate  the  thick  skin. 

Deep  phlegmon  under  the  plantar  aponeurosis  is  often  the  result  of 
injuries,  small  puncture-wounds  made  by  splinters,  needles,  etc.  Less 
frequently  it  is  transmitted  directly  from  the  toes  through  the  tendon- 
sheaths  or  lymphatics.  The  pain"  is  severe  on  account  of  the  tension 
between  the  aponeurosis  and  the  thick  skin.  The  swelling  and  fluctua- 
tion in  the  sole  of  the  foot  develop  more  slowly  than  the  swelling  and 
redness  on  the  dorsum,  hence  the  frequent  mistake  made  of  incising  on 
the  dorsum.  If  the  inflammation  extends  backward  to  the  tendon- 
sheaths  at  the  ankle,  it  is  usually  transmitted  rapidly  up  the  leg. 

Treatment.— The  treatment  of  all  these  phlegmonous  processes  is 
early  incision  parallel  to  the  nerves  and  tendons,  and  if  possible  at  a 
point  where  the  cicatrix  will  not  be  subjected  to  pressure  later,  so  prefer- 
ably on  the  inner  or  outer  border  of  the  foot  or  in  the  arch  of  the  sole. 

Chronic  Inflammations.— Among  the  chronic  inflammations  of  the 
soft  parts  should  be  mentioned  several  whose  nature,  whether  inflamma- 

(  773  ) 


774  DISEASES  OF  THE  ANKLE  AND  FOOT. 

tion,  hypertrophy,  trophic  disturbance,  or  tumor,  is  still  uncertain. 
Among  these  several  forms  of  keratosis  are  important  in  minor  surgery 
of  the  foot  more  on  account  of  their  frequency  than  for  their  surgical 
interest.  A  flat  circumscribed  keratosis  is  termed  callosity,  tyloma,  or 
tylosis.  According  to  Unna,  it  is  essentially  a  thickening  of  the  epider- 
mis with  flattening  of  the  layer  of  prickle-cells,  and  at  first  without 
hypertrophy  of  the  papillae.  If  irritated  for  a  longer  time,  the  prickle- 
cells  increase  and  the  papilla?  are  lengthened. 

Clavus,  or  corn,  is  a  more  advanced  form  of  induration  with  the  thick- 
ening of  the  strata  of  prickle-  and  granular-cells  around  the  edge 
and  the  hypertrophy  of  the  papilla?  shown  by  an  irritated  callosity. 
In  the  middle  the  conical  core  grows  down  into  the  corium,  which 
atrophies  and  becomes  indented.  The  pain  is  due  to  pressure  upon 
the  nerve  terminals.  Suppuration  may  develop  under  corns  from  small 
fissures  or  wounds  and  be  very  painful.  A  small  bursa  is  often  found 
under  old  corns.  If  it  becomes  infected  and  suppurates,  the  pain  is 
intense.  If  the  pus  perforates  outward,  a  small  fistula  is  formed;  the 
pain  then  subsides,  but  each  time  the  opening  closes  the  inflammation 
and  painful  retention  recur.  As  the  bursa  occasionally  communicates 
with  the  tendon-sheaths  and  joints  beneath,  the  inflammation  may 
spread  to  these.  Although  the  common  cause  is  the  pressure  of  tight 
shoes,  tylosis,  and  somewhat  less  frequently  clavus,  has  been  seen  with- 
out previous  long-continued  traumatic  irritation.  Pitres  and  Vaillard 
found  inflammatory  and  fibrous  degeneration  of  the  corresponding 
nerves  of  the  foot  in  all  cases  of  callosities;  probably  this  was  the  result 
rather  than  the  cause  of  the  changes  in  the  skin. 

The  treatment  is  the  wearing  of  proper  shoes;  small  corns  then 
usually  disappear.  If  the  corn  is  cut,  the  core  should  be  removed 
thoroughly  under  aseptic  precautions  without  causing  bleeding.  Some 
surgeons  soak  the  corn  before  cutting;  others  state  that  it  can  be  dis- 
tinguished from  sound  skin  better  if  hard.  The  best  way  to  soften 
a  corn  is  to  apply  salicylic  acid,  either  the  plaster  (empl.  sapon.  salicyl. 
10-20  per  cent.),  the  rubber  plaster  (30-50  per  cent,  salicylic  acid),  a 
10  per  cent,  solution  in  collodion,  or  in  substance.  The  corn  often 
separates  off  of  itself  after  these  applications.  Stronger  cauterization 
is  not  advisable.  Or  instead  a  ring  may  be  worn  to  protect  it,  facilitate 
its  removal,  and  lessen  the  pain.  The  small  bursa  if  opened  during 
operation  or  suppurating  should  be  opened  freely  or  excised  or  cauterized. 

Tuberculosis  of  the  skin  and  lupus  are  not  uncommon  on  the  foot. 
The  former  is  usually  confined  chiefly  to  the  skin  and  has  no  peculiarities 
in  the  foot.  Lupus  is  found  usually  on  the  toes  and  dorsum.  As  in 
the  hand,  it  is  very  often  papillar  (lupus  papillosus  or  verrucosus)  and 
superficial,  and  therefore  easily  cured  by  scraping  and  cauterizing  with 
the  actual  cautery;  but  even  this  form  may  extend  deeply.  Lupus 
hypertrophicus,  the  form  described  as  resembling  epithelioma,  with 
exuberant  nodular  growth  of  epithelium,  is  often  found  on  the  foot,  as 
on  the  hand  and  arm.  If  it  penetrates  deeply,  the  fascia,  tendons, 
periosteum,  bone,  and  the  joints  may  be  gradually  involved,  and  pha- 


DISEASES  OF  THE  NAILS  OF  THE  FOOT.  775 

langes  or  even  the  toes  cast  off  (lupus  mutilans).  Fusion  of  the  toes 
and  contractures  may  result  from  the  cicatrization  of  the  ulcers.  If 
large  areas  are  involved  and  the  cicatricial  contraction  extends  around 
the  foot  or  leg,  the  bloodvessels  and  lymphatics  become  engorged  and 
the  foot  greatly  enlarged.  This  together  with  the  nodular  patches  of 
lupus  may  produce  great  deformity.  Scraping,  cauterization,  excision, 
and  bandaging  may  improve  the  condition  but  never  bring  about 
recovery.     Therefore  amputation  is  sometimes  advisable. 

Syphilis  almost  never  occurs  as  a  primary  lesion  in  the  soft  parts.  In 
a  few  instances  we  have  seen  a  chancroid  (ulcus  molle)  on  or  between 
the  toes,  transmitted  by  the  fingers  from  an  ulcer  on  the  penis.  Papular 
syphilides  are  not  rare  about  the  nails  and  between  the  toes.  The  sole 
is  a  favorite  site  of  the  squamous  syphilide  (psoriasis  plantaris  syphil- 
itica). It  may  be  confused  with  tylosis  if  associated  with  callosities 
and  fissures.  Occasionally  it  is  very  painful.  Gummatous  syphilides, 
serpiginous  ulcers,  and  deep  gummata  also  occur  on  the  foot.  The 
latter  if  broken  down  but  not  yet  ulcerating  may  be  confused  with 
abscess. 

Leprosy  of  the  foot  is  rare  in  Germany  [and  America].  (See  A.  v. 
Bergmann  in  Deutsche  Chirurgie,  Lieferung  Nr.  10b). 

Madura  foot  (mycetoma,  fungus  foot  of  India)  is  a  disease  of  the  foot 
endemic  in  India  but  rarely  met  with  in  Germany  [or  America].  It  is 
a  chronic  purulent  inflammation  of  the  foot,  beginning  in  the  soft  parts, 
burrowing  throughout  the  entire  foot,  and  destroying  the  tendons,  bones, 
and  joints.  The  pus  contains  black,  yellow,  and  white  granules,  similar 
to  but  larger  than  those  of  actinomycosis,  so  that  Tusini  has  recently 
regarded  the  condition  as  being  a  genuine  actinomycosis.  In  the  first 
stages  conservative  measures,  incision,  scraping,  and  excision,  are 
apparently  indicated;  but  later  amputation,  if  the  foot  is  thickened  or 
honeycombed.  The  similarity  of  the  two  diseases  has  been  emphasized 
recently  by  Bollinger,  who  reports  a  case  of  genuine  actinomycosis  of 
the  foot  which  started  in  the  skin,  but  did  not  produce  any  extensive 
destruction  of  the  bone  until  several  decades  later. 

Ainhum  or  spontaneous  dactylolysis,  is  the  term  applied  to  a  spon- 
taneous amputation  of  the  fingers  and  toes  which  is  met  with  most 
often  among  African  negroes.  Most  frequently  it  affects  the  fifth  toe, 
less  so  the  fourth,  and  never  the  other  toes.  Only  one  instance  of  this  sort 
is  known  among  Europeans.  (Wiedemann.)  [Herrick  (Philadelphia 
Medical  Journal,  February  5,  1898)  describes  the  case  of  a  negro  who 
had  lived  in  Illinois  thirty  years  (cited  by  Hyde,  1900),  and  Crocker 
(1903)  a  case  of  Johnson  Smith  at  the  Seamen's  Hospital,  Greenwich, 
England.] 

DISEASES   OF  THE  NAILS  OF  THE  FOOT. 

Only  a  few  of  the  diseases  of  the  nails  are  of  surgical  interest. 
Onychogryphosis. — Of  the  trophic  disturbances,  the  severe  forms  of 
onychogryphosis,  in  which  there  are  enormous  growths  similar  to  the 


776  DISEASES  OF  THE  ANKLE  AND  FOOT. 

lioofs  and  claws  of  animals,  may  occasionally  demand  removal  of  the 
nail.  These  deformities  are  seen  most  frequently  on  the  great  or  little 
toe  of  elderly  people,  but  also  occur  on  the  other  toes.  Niigeli  reports 
very  large  cornifications  on  all  ten  toes.  These  growths  are  caused 
chiefly  by  the  pressure  of  the  shoe,  but  once  started  the  deformivy 
increases  after  the  irritation  has  ceased. 

Treatment. — The  growth  should  be  softened  in  a  bath  of  potassium 
carbonate,  and  then  cut  off  and  the  nail  filed  down  smooth  and  covered 
with  an  impervious  rubber  plaster  to  prevent  drying.  (Heller.)  If  the 
condition  is  painful,  the  nail  can  be  extracted.  The  other  trophic  dis- 
turbances of  the  nail  due  to  nervous  or  general  skin  diseases  or  parasites 
are  not  surgical. 

Onychia  and  Paronychia. — The  acute  and  chronic  forms  of  onychia 
and  the  acute  forms  of  paronychia  are  the  same  in  the  toes  as  in  the 
fingers,  but  much  less  frequent.  (See  Diseases  of  the  Wrist  and  Hand.) 
Onychia  maligna  is  a  term  applied  to  a  peculiar  chronic  ulceration  of 
the  matrix  occurring  in  the  toes  as  in  the  fingers.  It  is  probable  that  it 
is  generally  tuberculous,  but  in  regard  to  obstinate  ulcerating  processes 
about  the  nails  one  should  bear  in  mind  that  the  recovery  of  such  ulcers 
can  be  prevented  by  the  constant  irritation  of  the  shoe  and  uncleanliness. 
The  papular  syphilides  and  the  ulcers  which  are  found  especially  at  the 
edge  of  the  nail,  occasionally  horseshoe  shape  around  the  nail,  are  to  be 
sharply  distinguished  from  onychia  maligna. 

Treatment. — In  all  obstinate  cases  the  nail  should  be  extracted,  as  it 
prevents  drainage  and  irritates  the  ulcer  constantly.  Its  loss  is  less 
important  than  on  the  fingers.  The  tuberculous  onychia  should  be 
scraped  out  thoroughly  and  burned  with  the  actual  cautery  if  it  does 
not  yield  readily  to  conservative  treatment  (lead  nitrate,  antiseptics). 

Clavus  Subungualis. — Clavus  subungualis  is  a  condition  that  is  fre- 
quently overlooked;  it  makes  walking  and  standing  very  painful,  and 
should  always  be  thought  of  unless  the  pain  is  referable  to  ingrowing 
toenail.  The  results  of  treatment,  splitting  or  extracting  part  of  the 
nail  and  removing  the  callosity,  are  very  grateful. 

Ingrowing  Toenail. — Ingrowing  toenail  (onyxis,  onychia,  ony- 
chauxis, onychogryphosis,  unguis  incarnatus)  is  a  very  common  con- 
dition affecting  most  frequently  the  outer  border  of  the  great  toe,  less 
so  the  inner  border  or  both  sides  of  the  nail,  and  rarely  the  other  toes. 
The  free  edge  and  side  of  the  nail  press  against  and  irritate  the  skin, 
which  becomes  inflamed,  swollen,  and  gradually  thickened  around  and 
over  the  edge  of  the  nail.  Then  the  nail-fold  or  mantle  suppurates, 
granulations  form,  and  the  process  advances  backward,  although 
rarely  extending  to  the  upper  part  of  the  nail-fold.  The  entire  toe  may 
become  swollen  and  lymphangitis  develop.  The  pain  may  be  so 
severe  that  the  patient  cannot  wear  a  shoe  and  even  without  it  have  to 
favor  the  foot.  If  the  nail  is  curved  sharply  sideways,  or  flat  and  bent 
sharply  at  the  lateral  edge,  or  movable  with  its  free  edge  extending  far 
back,  it  favors  the  development  of  the  affection;  also  if  the  toe  is  broad 
and  the  skin  grows  up  at  the  sides  and  in  front.     Short  and  narrow 


DISEASES  OF  THE  NAILS  OF  THE  FOOT.  777 

shoes  are  the  immediate  cause,  by  pressing  the  skin  against  the  nail. 
The  second  toe  is  sometimes  forced  under  the  first  and  presses  the  skin 
upward  and  laterally  against  the  nail,  so  it  has  been  recommended  to 
bandage  the  second  toe  upon  the  first  or  to  separate  them. 

The  fact  that  the  condition  also  occurs  in  bedridden  patients  and  is 
seen  ehienV  in  younger  persons  indicates  a  certain  predisposition  of  the 
tissues.  Improper  paring  of  the  nails  is  a  very  significant  cause,  as 
known;  if  the  nail  is  cut  too  far  back  or  unevenly,  the  sharp  edge  easily 
irritates  the  skin.  Standing  or  walking  for  a  long  time  in  tight  shoes, 
trauma,  frostbite,  etc.,  combined  with  the  bacteria  usually  present  in  the 
skin  are  the  causes  of  inflammation  and  suppuration.  The  nail  is 
passive  in  the  process,  the  skin  being  rubbed  against  it,  irritated,  and 
infected.  The  prophylaxis  is  well-fitting  shoes  and  proper  care  of  the 
nails.      The  side  of  the  nail  should  project  beyond  the  skin  in  front. 

Treatment. — Attempts  have  been  made  to  separate  the  nail  from  the 
nail-fold  by  placing  pieces  of  lead,  iron,  tin-foil,  lint,  gauze,  etc.,  between 
them.  Iodoform  gauze  is  better,  and  should  be  renewed  until  the 
ulceration  has  healed  and  the  nail  has  grown  out  beyond  the  affected 
spot.  The  granulations  are  cauterized.  Removing  a  triangular  piece 
from  the  edge  of  the  nail  may  help  to  allay  the  irritation  till  the  spot  has 
healed.  In  order  to  lift  up  and  cut  off  the  nail  more  easily,  it  has  been 
shaved  or  filed  off, or  painted  or  swabbed  with  a  1 :4  solution  of  potassium 
carbonate,  or  caustic  potash,  or  collodion  or 
traumaticin  (gutta-percha  10,  chloroform  SO)  Fig.  493 

painted  on  between  the  nail  and  the  granu- 
lations.    The  skin  may  be  pressed  away  at  I 
the  same  time  by  means  of  a  small  pad  fast-  I 
ened  on  with  adhesive  plaster. 

Operation  is  preferable  for  severe  cases  or 
for  recurrence.  Of  the  various  methods  of 
Temoving  the  nail  or  the  soft  parts,  or  both, 
few  are  satisfactory.  The  frequency  of  re- 
currence demonstrates  the  necessity  of  remov- 
ing part  of  the  matrix  with  the  nail  and  skin. 
It  should  be  remembered  that  the  nail  and 
its  matrix  extend  beyond  the  lunula  and  the 
skin-fold.  The  simplest  method  and  the  one 
in  general  use  in  Germany  is  to  make  a  lateral 
curved  incision  below  the  ulcerated  skin  (Fig. 
493),  and  extending  about  §  inch  back  of  the 

nail-fold.  From  this  latter  point  a  straight  incision  is  made  directly  for- 
ward through  the  nail;  the  included  skin,  nail,  nail-fold,  and  matrix  are 
excised,  being  careful  not  to  leave  any  matrix  or  nail  at  the  side  or  upper 
angle.  The  edge  of  the  skin  is  then  applied  and  held  by  the  dressing 
against  the  edge  of  the  nail.  Unless  considerable  skin  has  been  removed 
on  account  of  ulceration,  and  in  the  absence  of  infection,  the  patient  is 
usually  about  in  S  days.  The  operation  can  be  performed  under  cocaine 
with  a  small  tourniquet  applied  around  the  toe  above.     Anger  inserts 


778  DISEASES  OF  THE  ANKLE  AND  FOOT. 

the  knife  above  the  mantle,  makes  a  straight  incision  forward  along  the 
side  of  the  nail  or  in  sound  skin,  retracts  the  skin-flap  thus  made  and 
removes  a  portion  of  nail  and  matrix  and  all  diseased  tissue,  and 
then  sutures  or  binds  the  flap  back  in  place.  Recovery  is  supposed 
to  be  rapid  and  permanent.  Quenu,  proceeding  on  the  assumption 
that  the  nail  only  grows  from  the  upper  part  of  the  matrix,  extracts  the 
nail  and  then  excises  a  rectangular  piece  from  the  upper  part  of  the 
matrix  and  covers  in  the  exposed  area  with  a  small  skin-flap.  Dardignac 
recommended  this  method.  In  order  to  excise  the  matrix  with  greater 
ease  and  certainty,  he  dissected  back  a  somewhat  broader  skin-flap. 
If  the  nail  is  ingrowing  on  one  side  only,  a  piece  of  the  matrix  can  be 
removed  on  the  affected  side,  but  if  on  both  sides,  the  matrix  is  excised 
straight  across.  The  results  are  supposed  to  be  good ;  the  growth  of  skin 
over  the  defective  area  of  the  matrix  is  sufficiently  resistant  to  prevent 
discomfort,  even  when  the  entire  nail  is  absent.  Baumgartner  prefers  to- 
preserve  the  bed  and  matrix  intact  and  therefore  simply  removes  the  nail. 


DISEASES  OF  THE  TENDON-SHEATHS  AND  BURS.S  OF  THE  FOOT. 

Diseases  of  the  Tendon  sheaths  in  the  Foot. — The  diseases  of  the 
tendon-sheaths  of  the  foot  are  less  important  than  those  of  the  tendon- 
sheaths  of  the  hand.  In  the  toes  the  sheaths  are  especially  subject  to 
acute  suppuration  after  injuries.  As  the  arrangement  of  the  flexor 
sheaths  is  the  same  as  in  the  fingers,  any  inflammation  in  them  can 
spread  rapidly  to  the  metatarsals  and  after  perforating  through  the 
sheaths  spread  through  the  sole  of  the  foot.  All  other  forms  of  acute 
and  chronic  inflammation  are  of  slight  importance.  Tuberculosis  of 
the  sheaths  is  seen  occasionally.  The  sheaths  of  all  the  tendons  about 
the  ankle-joint  except  the  tendo  Achillis  are  well  developed  and  inflam- 
mations of  the  same  are  more  important. 

Anatomy. — The  tendon-sheath  of  the  common  extensors  of  the  toes 
begins  about  2  inches  (according  to  Hartmann  2h  inches)  above  a  line 
connecting  the  tips  of  the  malleoli,  and  ends  about  1  inch  below  this 
line  over  the  middle  of  the  third  cuneiform.  In  its  upper  half  it  is  cov- 
ered by  reinforcing  fibres  of  the  crural  fascia,  the  so-called  ligamentum 
transversum  cruris.  Between  the  lower  border  of  this  ligament  and  the 
ligamentum  cruciatum  cruris  the  sheath  is  covered  merely  by  very  thin 
fascia  for  a  distance  of  about  \  inch.  From  this  point  it  extends  another 
2  inch  downward  beneath  the  fascia  on  the  dorsum.  Effusions  in  the 
sheath  can  therefore  distend  the  same  mainly  at  two  points;  below  the 
ligamentum  cruciatum — that  is,  just  below  the  line  of  the  malleoli,  and 
between  the  ligamentum  cruciatum  and  transversum  above  this  line. 
Any  distention  is  usually  visible  first  at  the  former  point,  although  in 
many  instances  it  appears  at  both  places,  in  which  case  through-fluctua- 
tion can  be  obtained  beneath  the  ligamentum  cruciatum. 

The  sheath  of  the  extensor  hallucis  begins  about  1^  inches  (according 
to  Hartmann  f  inch)  above  the  line  of  the  malleoli,  and  usually  extends 


DISEASES  OF  THE  TENDON  SHEATHS  AND  BURS^E  OF  FOOT.     779 

to  the  base  of  the  first  metatarsal,  exceptionally  farther  forward.  In 
its  upper  portion  it  is  covered  by  the  Ligamentum  transversum,  in  its 

middle  portion  by  both  arms  of  the  ligamentum  erueiatnm,  and  the  last 
V  inch  is  covered  only  by  fascia.  Effusions  therefore  cause  distention 
chiefly  at  the  lower  end  at  the  level  of  the  base  of  the  first  metatarsal, 
ami  of  somewhat  long  oval  form;  but  bulging  may  also  occur  in  the 
short  intervals  between  the  two  arms  of  the  ligamentum  erueiatum  and 
between  the  ligaments  erueiatum  and  transversum. 

The  sheath  of  the  tibialis  amicus  begins  2  inches  above  the  line  of  the 
malleoli  (Hartmann  2\  inches),  and  is  covered  in  its  upper  portion  by 
the  ligamentum  transversum,  in  the  middle  by  the  upper  arm  of  the  liga- 
mentum erueiatum,  and  its  lower  portion  lies  between  this  arm  and  the 
lower  arm  of  the  same  ligament,  which  latter  passes  over  the  tendon 
below  the  end  of  the  sheath.  The  sheath  is  therefore  more  easily  dis- 
tensible in  its  uncovered  portion  between  the  two  arms  of  the  ligamen- 
tum erueiatum  at  the  level  of  the  tibiotarsal  joint. 

The  tendons  of  the  two  peronei  have  a  common  sheath  which  divides 
into  two  about  H  to  2\  inches  (Hartmann,  If  to  If  inches)  above  the 
tip  of  the  external  malleolus,  these  in  turn  extending  to  a  point  h  inch 
above  the  tuberosity  of  the  fifth  metatarsal.  According  to  Hartmann, 
the  sheath  of  the  peroneus  brevis  extends  to  the  level  of  Chopart's  joint, 
and  that  of  the  peroneus  longus  to  the  groove  in  the  cuboid.  If  the 
common  sheath  is  distended  by  chronic  effusions,  etc.,  the  swelling  is 
of  elongated  spindle  shape  and  chiefly  behind  and  above  the  malleolus. 
It  may  also  bulge  between  the  retinacula  peroneorum  or  at  the  anterior 
end  of  the  sheath  at  the  front  part  of  the  calcaneum.  In  the  sole  of  the 
foot  the  peroneus  longus  has  a  sheath  separate  from  the  other  tendon 
sheaths,  but  with  walls  so  thin  that  in  the  event  of  suppuration  perfora- 
tion easily  occurs  in  either  direction. 

The  tendons  of  the  tibialis  posticus,  flexor  longus  digitorum,  and 
flexor  longus  hallucis  are  separated  from  each  other  by  fibrous  septa. 
The  sheath  of  the  first  of  those  muscles  begins  3  to  3  V  inches  (Hartmann, 
2\  inches)  above  the  tip  of  the  internal  malleolus.  Near  the  insertion 
of  the  tendon  the  sheath  is  tucked  in  like  a  bursa  between  the  tendon 
and  the  scaphoid,  while  the  broad  medial  surface  of  the  tendon  is 
attached  to  the  fascia.  The  sheath  of  the  flexor  digitorum  begins 
about  lh  inches  (Hartmann,  the  same)  above  the  malleolus  and  extends 
to  the  astragaloscaphoid  joint.  The  sheath  of  the  flexor  hallucis  begins 
f  inch  above  the  tip  of  the  malleolus  and  extends  slightly  farther  into 
the  sole.  The  sheaths  of  the  flexor  hallucis  and  flexor  digitorum  often 
communicate  where  they  cross  each  other. 

Effusions  in  the  sheaths  behind  the  malleolus  are  most  prominent 
above  the  ligamentum  laciniatum  (internal  annular  ligament),  less 
frequently  below  at  the  inner  border  of  the  sole,  but  are  never  very 
distinct  on  account  of  the  firmness  of  the  overlying  parts. 

Acute  inflammations  more  frequently  affect  the  sheaths  of  the  exten- 
sors and  peronei  than  those  of  the  flexors  situated  behind  the  internal 
malleolus.    Acute  dry  and  crepitant  or  mild  serous  tenosynovitis  occurs 


780  DISEASES  OF  THE  ANKLE  AND  FOOT. 

after  severe  exertion,  such  as  long  marches,  etc.;  or  as  the  result  of 
rheumatism.  If  neglected,  it  may  become  chronic.  Gonorrhceal 
tenosynovitis  not  infrequently  develops  in  the  sheaths  of  the  extensors, 
flexors,  and  peronei;  the  joint  is  often  uninvolved.  With  proper  treat- 
ment the  prognosis  is  good.  Suppuration  is  almost  always  by  trans- 
mission from  a  suppurating  wound  or  cellulitis.  After  the  sheath 
ruptures  the  suppuration  spreads  easily  into  the  deep  fascia  of  the  leg 
in  front  or  behind,  according  to  the  position  of  the  tendon. 

Of  the  chronic  serous  effusions,  aside  from  those  resulting  from 
acute  trauma,  rheumatism,  or  gonorrhoea,  the  tuberculous  is  the  most 
important.  It  occurs  in  the  form  of  a  hygroma  with  or  without  rice- 
bodies,  and  also  as  the  fungous  variety.  The  tendon-sheaths  of  the 
peronei  are  the  ones  most  frequently  affected.  A  tuberculous  hygroma 
is  almost  always  easily  diagnosed,  aside  from  the  etiology.  The  fungous 
form,  especially  in  the  sheaths  behind  the  malleoli,  may  present  diffi- 
culties. Where  the  form  and  extent  of  the  swelling  correspond  to  the 
limits  of  the  sheaths  as  described  above,  they  are  often  quite  character- 
istic, but  the  tuberculous  process  is  not  always  limited;  occasionally  it 
extends  into  the  loose  tissues  in  front  of  the  tendo  Achillis  or  higher  up 
in  the  leg.  Secondarily  it  may  involve  the  bones  and  joints,  but  the 
usual  process  is  in  the  reverse  direction;  in  the  case  of  the  peronei  the 
calcaneum  is  generally  the  primary  focus. 

Treatment. — The  acute  and  chronic  forms  of  tenosynovitis  usually 
yield  rapidly  to  compression  and  rest  and  leave  no  stiffness  if  appropri- 
ate massage  is  employed.  Suppuration  requires  free  incision.  In  the 
tuberculous  forms  iodoform  may  be  injected,  but  operation  is  often 
found  necessary.  The  latter  consists  of  free  incision  and  scraping,  or, 
better,  thorough  excision  of  the  tuberculous  tissue,  and  later  injection  of 
iodoform. 

Diseases  of  the  Bursae. — Views  differ  as  to  the  constancy  of  numerous 
small  bursas  in  the  foot  aside  from  the  one  between  the  tendo  Achillis 
and  the  tuberosity  of  the  calcaneum;  this  Hartmann  regards  as  con- 
stant. In  at  least  a  large  number  of  cases  other  small  bursa3  are  found 
and  they  become  important  by  reason  of  pathological  changes,  espe- 
cially the  "accidental"  bursa?  which  develop  beneath  the  skin  over 
bony  prominences  as  the  result  of  constant  pressure  of  shoes,  etc. 

The  bursa  achillea  anterior  or  retrocalcanea  has  recently  been  the 
subject  of  closer  study.  (Rossler.)  Diseases  of  the  same  are  frequently 
due  to  trauma,  single  or  repeated  attacks  of  gonorrhoea,  less  frequently 
articular  rheumatism,  gout,  influenza,  and  syphilis;  tuberculosis  of  the 
bursa  is  usually  secondary  by  transmission  from  the  calcaneum.  Dis- 
ease of  this  bursa  is  sometimes  evidenced  by  a  fluctuating  tumor  of  some 
size,  but  more  frequently  by  the  presence  of  a  small  swelling  beneath 
the  insertion  of  the  tendo  Achillis,  which  feels  like  a  thickening  of  the 
tuberosity  of  the  calcaneum.  In  the  gonorrhceal  form  the  swelling 
may  involve  the  adjacent  soft  parts  and  periosteum  of  the  calcaneum. 
Chronic  diseases  of  the  bursa,  in  addition  to  producing  thickening  of 
the  sac,  may  cause  an  actual   growth  of  the  periosteum,  which  Rossler 


ACUTE  INFLAMMA  TI0N8  OF  JOINTS  AND  BONES  OF  FOOT.     781 

has  compared  to  the  process  in  arthritis  deformans.  The  patients 
generally  complain  of  more  or  less  severe  pain  in  walking,  which  may 
radiate  into  the  calf.     The  effort  to  relax  the  tendo  Achillis  apparently 

leads  to  the  production  of  flat-foot. 

Treatment. — The  treatment  of  acute  bursitis  of  the  retrocalcaneal 
bursa  is  antiphlogistic,  especially  resl  and  pressure;  of  chronic  bursitis, 
application  of  moist  hot  compresses  and  massage.  Eventually  aspira- 
tion and  irrigation  if  necessary;  if  still  unsuccessful,  incision  and  irri- 
gation with  carbolic  acid,  or  packing  with  iodoform  gauze  to  obliterate 
the  bursa,  or  excision.  If  tuberculous, the  bursa  should  be  excised.  If 
necessary  the  tendo  Achillis  may  be  divided  and  sutured  at  the  end  of 
the  operation. 

Some  of  the  French  authors  maintain  that  the  painful  swelling  of  the 
heel  in  gonorrhoea  is  characteristic  (pied  blennorrhagique);  that  it  is 
due  to  a  periostitis  and  ostitis  of  the  calcaneum,  and  especially  to  involve- 
ment of  the  insertion  of  the  tendon  on  the  calcaneum.  We  believe, 
however,  that  it  is  the  bursa  which  is  usually  affected  and  that  the 
swelling  and  induration  of  the  surrounding  soft  parts — eventually 
the  periosteum — merely  resemble  disease  of  the  bone.  At  any  rate,  the 
latter  is  much  less  frequent  than  the  bursitis.  In  v.  Bergmann's  clinic  we 
recently  saw  a  case  of  this  sort,  which  finally  required  operation  after 
months  of  treatment;  the  thickened  and  almost  completely  obliterated 
bursa  was  excised  and  the  flat  mass  of  new  bone  projecting  backward 
from  the  calcaneum  was  chiselled  off  with  a  good  functional  result. 

It  is  possible  that  the  tenderness  on  the  surface  of  the  calcaneum 
which  is  not  infrequently  found  in  gonorrhoea  is  due  to  periostitis  at  the 
insertion  of  the  tendon.  Or  it  may  be  that  the  bursa  subcalcanea  is 
diseased.  The  author  once  excised  a  diseased  bursa  of  this  sort  with 
thickened  walls. 

The  bursa  achillea  posterior,  which  lies  between  the  tendon  and  the 
fascia  and  above  its  insertion,  is  also  affected  by  the  same  diseases,  but 
rarely.  Of  the  small  inconstant  bursa?,  those  on  the  metatarsals  and 
toes,  especially  the  metatarsophalangeal  bursa?,  are  the  ones  most  fre- 
quently affected.  Ganglion  is  a  very  rare  condition  in  the  foot  and 
occurs  almost  exclusively  on  the  dorsum  over  the  articulations  of  the 
cuboid.     Its  treatment  is  the  same  as  that  of  ganglion  of  the  wrist. 


ACUTE   INFLAMMATIONS   OF  THE  JOINTS  AND  BONES  OF 

THE  FOOT. 

Inflammations  of  the  Tibiotarsal  Joint. — As  a  rule  acute  effusions 
in  the  tibiotarsal  joint  first  distend  the  front  part  of  the  capsule  at  the 
sides  of  the  extensor  tendons.  If  the  soft  parts  are  not  much  involved, 
the  swelling  is  very  sharply  defined  and  gives  fluctuation.  Later  it 
appears  on  the  posterior  surface  of  the  joint  and  below  the  malleoli. 
In  acute  inflammations  the  soft  parts  are  usually  oedematous  and  red. 
The  slightly  extended  position  which  the  foot  commonly  assumes  in  the 


782  DISEASES  OF  THE  ANKLE  AND  FOOT. 

recumbent  position,  or  when  the  limb  is  suspended,  is  due  largely  to  the 
weight  of  the  forepart  of  the  foot.  Any  great  destruction  of  joint-surfaces 
is  rare  in  acute  inflammations  or  occurs  late,  even  in  the  case  of  suppu- 
ration, unless  the  latter  starts  in  the  bone.  On  the  other  hand,  the 
tendon-sheaths  about  the  joint  are  often  involved  early. 

The  acute  effusions  which  follow  fractures  and  sprains  of  the  foot 
are  generally  hemorrhagic,  rarely  serous  from  the  start;  later  a  chronic 
serous  synovitis  is  apt  to  develop  rather  frequently  after  such  injuries. 
The  suppuration  of  the  joint  following  penetrating  wounds,  fractures, 
and  dislocation  has  already  been  mentioned.  The  other  purulent 
processes  are  chiefly  due  to  suppuration  spreading  from  an  acute  osteo- 
myelitis of  an  adjacent  bone  or  from  a  phlegmonous  process — especially 
of  the  tendon-sheaths  about  the  joint;  they  may  occur  also  by  pysemic 
metastasis.  Acute  articular  inflammations  occur  in  a  number  of  infectious 
diseases.  The  joint  is  frequently  affected  in  rheumatism,  often  previous 
to  the  involvement  of  other  joints.  Gonorrhoeal  arthritis  is  a  very 
frequent  occurrence;  the  condition  is  characterized  by  intense  pain, 
usually  marked  swelling  of  the  soft  parts,  frequent  involvement  of  the 
tendon-sheaths,  and  great  tendency  to  the  development  of  ankylosis. 

Treatment. — Conservative  treatment  consists  essentially  in  the  appli- 
cation of  slight  compression  and  complete  immobilization  of  the  joint. 
It  is  important  to  remember  that  unless  properly  immobilized  the  foot 
is  apt  to  become  extended,  and  that  almost  all  inflammations  of  the 
ankle-joint  are  very  liable  to  be  followed  by  adhesions  and  shrinkage 
of  the  capsule.  The  impending  limitation  of  motion  can  be  prevented 
and  overcome,  to  some  extent  at  least,  by  appropriate  mechanical  treat- 
ment if  supported  by  energetic  exercise  on  the  part  of  the  patient; 
nevertheless  many  joints  become  permanently  stiffened.  In  inflamma- 
tions of  the  ankle-joint  the  foot  should  therefore  never  be  left  free,  but 
should  be  immobilized  in  strip  splints  or  plaster,  care  being  taken  that 
the  foot  is  at  a  right  angle  to  the  leg  and  in  the  mid-position  between 
inversion  and  eversion.  If  the  ankle-joint  becomes  ankylosed  in  any 
other  position,  it  almost  always  compromises  the  use  of  the  limb. 

The  existence  of  suppuration  is  indication  for  immediate  incisions  at 
either  side  of  the  extensor  tendons  in  front,  and  also  behind  the  joint 
if  necessary.  As  the  structure  of  the  joint  prevents  free  drainage,  the 
incision  should  be  kept  widely  open.  Oilier  recommended  removing 
part  of  the  malleoli  subperiosteally  through  posterior  incisions  to  give 
better  drainage. 

If  the  suppuration  is  from  osteomyelitis,  it  usually  suffices  to  open 
and  clean  out  the  focus  and  drain  the  joint  through  a  free  incision.  If 
free  drainage  is  not  obtained,  part  of  the  joint  should  be  resected,  the 
astragalus  rather  than  the  malleoli,  according  to  Oilier.  Or,  as  in 
Konig's  method,  the  articular  ends  of  the  tibia  and  fibula  may  be 
removed  and  the  malleoli  and  astragalus,  or  parts  of  the  same,  preserved 
if  possible.  It  is  only  in  the  very  severe  cases,  however,  in  which  necrosis 
of  the  separated  epiphysis  of  the  tibia  is  certain,  that  one  would  decide 
to  remove  subperiosteally  the  entire  articular  surfaces  of,:>the  tibia  and 


ACUTE  INFLAMMATIONS  OF  JOINTS  ANT)  BONES  OF  FOOT.     783 

fibula.  Osteomyelitis  of  the  astragalus  is  very  rare.  The  bone  should 
be  removed  it'  exposure  and  drainage  of  the  focus  and  incision  of  the 
ankle-joint  are  not  adequate;  also  if  the  mediotarsal  joint  is  involved. 

Suppuration  of  the  Joints  and  Bones  of  the  Tarsus. — Acute  suppu- 
ration of  the  joints  and  bones  of  the  tarsus  occurs  most  frequently 
after  puncture  and  incised  wounds,  compound  fractures  or  dislocations, 
or  by  transmission  from  a  phlegmon  of  the  soft  parts.  It  is  also  seen 
as  the  result  of  metastasis  in  pyaemia,  osteomyelitis,  gonorrhoea,  etc. 
The  affection  is  apt  to  be  transmitted  rapidly  from  one  joint  to  another 
on  account  of  the  numerous  communications,  and  to  involve  the  entire 
tarsus  and  tibiotarsal  joints.  The  only  exception  to  this  is  in  the  case 
of  osteomyelitis  of  the  calcaneum,  as  will  be  seen  later.  The  tendon- 
sheaths  are  easily  infected,  and  can  thus  transmit  the  phlegmonous 
process  upward  into  the  leg.  The  limb  then  becomes  swollen  throughout, 
the  skin  red  and  oedematous;  usually  the  foot  becomes  adducted, 
inverted,  and  extended.  As  the  effusion  is  always  under  pressure  on 
account  of  the  firmness  of  the  ligaments  the  pain  is  severe,  the  fever 
high,  and  the  articular  surfaces  and  bone  are  rapidly  destroyed.  Early 
incision  is  therefore  urgent.  The  anatomical  conditions  are  against  free 
drainage;  simple  incisions  of  the  joint  can  only  be  made  on  the  dorsum 
and  on  the  sides  of  the  foot,  as  in  the  sole  the  tense  soft  parts  make 
drainage  very  difficult;  so  it  often  becomes  necessary  to  resect  portions 
of  the  tarsus.  The  latter  measure  will  be  undertaken  even  more  promptly 
where  the  suppuration  originates  in  the  bone,  as  in  acute  osteomyelitis, 
for  as  a  rule  the  bone  rapidly  becomes  totally  necrotic  in  this  case  and 
always  demands  early  partial  or  complete  removal. 

The  calcaneum  has  rather  a  unique  position  in  this  respect  as  it  is 
the  most  frequent  site  of  osteomyelitis  of  all  the  tarsal  bones,  and  the 
pus  perforates  more  commonly  outward  than  into  the  joint,  in  contrast 
to  the  same  process  in  the  other  bones.  The  suppuration  may  be  limited 
to  the  posterior  portion  of  the  bone,  but  may  still  involve  the  calcaneo- 
astragaloid  joint,  or  the  whole  bone  may  be  infected  and  necrotic,  in 
which  case  the  adjacent  joints  are  usually  involved.  The  characteristic 
swelling  in  the  heel  below  the  malleoli  is  accompanied  early  by  inflam- 
mation of  the  soft  parts,  and  severe  pain  makes  the  diagnosis  simple 
in  acute  cases.  In  subacute  cases,  or  if  seen  late  in  the  acute  stage, 
when  necrosis  and  fistulas  are  present,  the  differentiation  from  tubercu- 
losis may  be  difficult. 

Treatment. — The  treatment  consists  in  chiselling  out  all  diseased 
bone  as  early  as  possible  through  a  curved  outer  incision,  the  same  as 
for  resection  or  excision  of  the  calcaneum.  If  this  does  not  check  the 
process,  one  may  wait  for  demarcation  and  a  new  growth  of  periosteum 
to  take  place;  the  latter  is  very  important  for  the  later  function  of  the 
foot.  If  the  joints  of  the  calcaneum,  especially  the  calcaneo-astragaloid, 
are  involved  secondarily,  or  if  the  whole  bone  is  necrotic,  it  should  be 
excised. 

Acute  Inflammations  of  the  Bones  and  Joints  of  the  Metatarsus 
and  Toes. — Ajute  inflammations  of  the  bones  and  joints  of  the  metatar- 


784  DISEASES  OF  THE  AXKLE  AXD  FOOT. 

sus  and  toes  are  most  frequently  due  to  injuries,  phlegmon,  and  ulceration 
of  the  soft  parts.  Acute  suppurative  osteomyelitis  of  the  metatarsals 
seldom  attacks  the  toes,  but,  on  the  other  hand,  is  generally  associated 
with  disease  of  numerous  other  bones.  Acute  articular  rheumatism 
sometimes  attacks  these  joints,  also  gonorrhoea.  In  the  latter  case 
there  is  usually  marked  swelling  of  the  joints  and  surrounding  soft 
parts,  and  the  process  is  very  painful  and  stubborn;  it  may  be  confused 
with  other  acute  inflammations,  especially  attacks  of  podagra.  In  the 
course  of  the  infectious  diseases  periostitis  and  osteomyelitis  of  the 
metatarsals  are  occasionally  seen,  which,  if  subacute  or  chronic,  produce 
swelling  and  oedema  of  the  dorsum  that  present  a  picture  similar  to  the 
so-called  "tumor  of  the  foot."  (See  Fractures  of  the  Metatarsus.)  A 
diagnosis  is  possible  only  by  careful  examination  and  longer  observation. 
Treatment. — Suppuration  of  the  metatarsals  and  toes  is  treated  on 
general  principles.  If  the  tarsometatarsal  joints  are  affected,  the  suppu- 
ration may  extend  to  the  tarsus.  If  suppuration  of  the  joints  is  not 
checked  by  incision  and  drainage,  the  joints  may  have  to  be  resected 
or  the  toes  amputated.  In  general  it  is  more  important  to  preserve  the 
great  toe  than  the  others,  so  that  resection  is  preferable  in  this  case  to 
amputation  if  possible.  In  the  case  of  the  other  four  toes  the  decision 
is  made  more  readily  in  favor  of  amputation  or  exartieulation.  Suppu- 
ration is  more  commonly  met  with  in  the  metatarsophalangeal  joint  of 
the  great  toe  than  in  the  others.  Good  results  can  be  obtained  if  the 
sesamoid  bones  and  head  of  the  basal  phalanx  can  be  preserved  and 
enough  of  the  articular  surface  of  the  metatarsal  left  to  give  support  to 
the  head.  Suppurative  osteomyelitis  of  a  metatarsal  is  treated  as  usual: 
free  incision,  preferably  on  the  dorsum,  exposure  of  the  sequestrum  by 
chiselling,  and  removal.  In  case  of  suppuration  or  necrosis  involving 
the  entire  metatarsal,  the  question  of  preserving  the  toe  depends  again 
upon  whether  it  is  the  hallux  or  one  of  the  other  four  that  is  affected. 
In  children  amputation  of  the  four  last  metatarsals  and  toes  is  advisable 
if  the  epiphyses  of  the  lower  ends  of  the  metatarsals  and  the  phalangeal 
joints  are  suppurating,  because  the  cicatricial  contraction  and  disturb- 
ance in  growth  produce  shortening,  atrophy,  and  contractures  that  are 
later  very  troublesome  and  generally  necessitate  removal  of  the  toes. 
On  the  other  hand,  one  always  hesitates  to  remove  the  great  toe  because 
of  its  importance.  So  conservatism  is  indicated,  particularly  when  the 
upper  epiphysis  of  the  metatarsal  can  be  saved,  as  it  is  apt  to  produce 
a  fairly  adequate  amount  of  new  bone. 


CHRONIC  INFLAMMATIONS   OF  THE  BONES  AND  JOINTS  OF 

THE  FOOT. 

Chronic  Rheumatism. — Chronic  rheumatism  not  infrequently  affects 
the  phalangeal  joints  and  leaves  a  certain  amount  of  stiffness.  In  the 
ankle-joint  it  is  more  serious,  as  it  may  produce  a  troublesome  contrac- 
ture if  the  position  of  the  foot  is  neglected.    Gonorrhoeal  arthritis  in  the 


CHRONIC  INFLAMMATIONS  OF  BONES  AND  JOINTS  OF  FOOT.     785 

tibiotarsal  and  metatarsophalangeal  joints  (especially  the  first)  is  often 
followed  by  a  chronic  deforming  inflammation  if  the  patient  walks  too 

soon  or  if  then-  arc  frequent  attacks. 

Arthritis  Deformans. ---Arthritis  deformans  of  the  ankle-joint  is  most 
frequently  met  with  after  injuries  of  the  joint,  such  as  fractures  of  the 
malleoli,  etc.  It  occurs  also  in  old  people  without  apparent  cause.  In 
the  tarsus  and  toes  it  is  very  often  the  result  of  deviations  or  contractures 
of  the  joints,  such  as  hallux  valgus,  pes  valgus,  etc.;  hut  without  such 
local  causes  it  is  more  rare. 

Treatment. — The  surgical  treatment  of  the  above  affections  is  limited 
chiefly  to  overcoming  the  deformity  and  contracture.  Severe  pain  may 
necessitate  resection,  or  amputation  in  the  case  of  the  toes. 

Gout. — Gout  (arthritis  urica,  podagra)  is  of  greater  importance.  Its 
favorite  points  of  attack  are  the  joints  of  the  toes,  particularly  the 
1  Metatarsophalangeal  joint  of  the  hallux.  Its  chief  significance  for  the 
surgeon  lies  in  the  fact  that  it  is  not  apt  to  be  mistaken  for  other  forms 
of  joint  inflammation.  The  attacks  are  characterized  by  a  more  or  less 
intense  inflammation  and  swelling  of  the  joint  and  surrounding  tissues, 
which  often  begins  suddenly  and  subsides  gradually  at  the  end  of  several 
days.  Frequently  repeated  attacks  are  followed  by  a  permanent  deposit 
of  uric  acid  and  urates  in  the  cartilage  and  capsule  of  the  joint  and 
surrounding  soft  parts.  In  the  latter  there  are  sometimes  nodular 
deposits  of  uric  acid  containing  material  resembling  chalk  (gout  nodules, 
tophi).  The  deposits  may  exist  for  a  long  time  without  producing  any 
severe  disturbance.  Occasionally  they  break  down,  suppurate,  and 
lead  to  the  formation  of  fistulas. 

Treatment. — The  treatment  of  gout  and  its  attacks  belongs  to  medi- 
cine and  the  internist.  The  local  treatment  of  attacks  is  limited  to 
attempts  to  alleviate  the  pain,  elevation  of  the  limb,  inunctions,  envelop- 
ment in  cotton  or  moist  warm  compresses.  In  many  cases  cold  com- 
presses or  the  ice-bag  give  comfort.  Morphine  is  at  times  indispensable. 
The  veteran  "podagrist"  usually  takes  care  of  the  attacks  himself  and 
has  certain  favorite  internal  remedies.  Against  surgical  measures,  such 
as  incision — occasionally  made  on  a  wrong  diagnosis — the  warning 
should  be  given  that  they  are  never  beneficial  and  often  do  harm.  The 
only  provocation  for  surgical  interference  is  suppuration  in  a  very 
diseased  joint  filled  with  large  urate  deposits,  due  to  ulceration  of  the 
overlying  skin.  This  is  frequently  the  case  in  the  great  toe.  Resection 
of  the  joint  may  be  attempted,  but  in  elderly  people  amputation  of  the 
toe  is  preferable.  Large  urate  deposits  in  the  soft  parts  may  be  excised 
or  scraped  out  with  the  sharp  spoon  if  they  become  troublesome  by 
reason  of  their  size  or  situation  or  if  they  suppurate.  Stiffness  of  the 
joint,  contracture,  ankylosis  in  a  faulty  position,  or  subluxation  may 
occasionally  require  surgical  treatment. 

Syphilitic  Affections. — The  syphilitic  inflammations  of  the  bones  and 
joints  of  the  foot  are  of  less  importance  and  show  few  variations  in  com- 
parison with  the  local  manifestations  of  syphilis  elsewhere.    The  various 
Vol.  Ill  —50 


786  DISEASES  OF  THE  ANKLE  AND  FOOT. 

forms  of  joint  syphilis  are  much  less  frequent  in  the  tibiotarsal  joint  than 
in  the  favorite  sites,  the  knee  and  elbow.  In  the  tarsus,  hyperostoses  may 
occur  in  the  congenital  form,  and  gummatous  processes  later  in  life  in  the 
acquired  form  of  syphilis.  Dactylitis  syphilitica  is  the  same  process 
in  the  toes  as  in  the  fingers;  it  occurs  in  the  congenital  and  late  in  the 
acquired  form  of  syphilis.  The  periostitis  or  central  ostitis  which  pro- 
duce the  tumefaction  of  the  bone  may  disappear  spontaneously  or  lead  to 
suppuration  and  necrosis.  Effusions  also  occur  in  the  synovial  cavities 
with  swelling  of  the  articular  ends  of  the  bones.  In  children  it  may  be 
difficult  to  distinguish  the  disease  from  tuberculous  spina  ventosa,  espe- 
cially as  congenital  syphilis  and  tuberculosis  are  often  found  coexistent. 
The  treatment  is  specific.     Necrotic  bone  should  be  removed. 


TUBERCULOSIS  OF  THE  JOINTS   AND  BONES  OF  THE  FOOT. 

Tuberculosis  is  the  most  important  of  the  chronic  inflammations  of 
the  bones  and  joints  of  the  foot.  It  also  has  a  conspicuous  position  in 
the  scale  of  frequency  of  joint  tuberculosis  in  general. 

Frequency. — Billroth  and  Menzel  give  tuberculosis  of  the  skeleton  of 
the  foot  sixth  place  in  order  of  frequency  of  joint  tuberculosis.  A  few 
more  recent  authors  give  it  second  place  with  disease  of  the  skeletal 
trunk  first.  The  value  of  such  statistics  is  limited  as  they  vary  with 
the  material  from  which  they  are  derived.  The  same  applies  to  the 
data  with  reference  to  the  site  of  the  original  focus  in  tuberculosis  of 
the  foot.  Mondan's  statistics  of  117  cases  examined  at  operation  or 
post-mortem  in  Ollier's  clinic  give  114  primary  osseous,  31  primary 
synovial,  and  25  cases  of  doubtful  origin.  Among  the  114  primary 
osseous  cases:  the  calcaneum  was  diseased  in  40,  the  astragalus  in  29, 
tibia  14,  fibula  2,  cuneiforms  5,  metatarsals  5,  cuboid  4,  scaphoid  3, 
and  in  12  several  bones  simultaneously.  The  small  number  of  primary 
synovial  cases  in  these  statistics  is  due  to  the  fact  that  the  cases  of  purely 
synovial  tuberculosis  heal  more  easily  than  those  due  to  large  osseous 
foci,  and  so  come  to  autopsy  less  frequently.  The  number  of  cases  of 
disease  of  the  metatarsals  and  toes  is  small  because  they  are  based  upon 
clinical  observations  and  are  therefore  the  cases  to  which  little  attention 
is  paid  as  they  are  mostly  ambulant. 

Tuberculosis  of  the  foot  develops  and  spreads  differently  according 
to  its  site,  so  that  an  anatomical  classification  is  of  a  certain  clinical 
value. 

Tuberculosis  of  the  tibiotarsal  joint  in  the  greater  majority  of  cases 
starts  primarily  in  the  bone,  occasionally  at  several  points,  and  most 
frequently  in  the  astragalus.  Small  foci  are  also  found  under  the  car- 
tilage or  at  the  margin  of  the  synovialis  in  the  tibia  and  fibula;  if  the 
joint  is  greatly  destroyed,  they  are  easily  overlooked  in  operating  and 
the  condition  regarded  as  primary  of  the  synovialis.  Large  foci  with 
or  without  a  sequestrum  also  occur  in  the  epiphysis  of  the  tibia,  less 
often  in  the  fibula.     (Fig.  494.)     The  tibiofibular  joint  is  rarely  intact 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES  OF  THE  FOOT.     787 

if  the  disease  b:  of  longer  standing.  'The  process  spreads  easily  to  or 
from  the  calcaneo-astragaloid  joint;  it  can  also  spread  forward  and 
completely  surround  the  tarsus  with  diseased  tissue. 

In  71  cases  operated  upon  by  Oilier  the  primary  focus,  according  to 
Vallas,  was  in  the  astragalus  in  22,  the  calcaneum  in  13,  the  scaphoid 
in  3,  the  cuboid  in  1,  in  the  fork  of  the  malleoli  in  9,  and  in  the  syno- 
vialis  in  23.  The  small  number  of  primary  synovial  cases  is  possibly 
also  explained  here  by  the  statistics  being  taken  from  only  the  severe 
and  therefore  operated  cases.  Riedel,  who  operated  upon  every  case 
of  tuberculous  arthritis  of  the  foot  as  soon  as  the  diagnosis  was  estab- 
lished, found  the  percentage  of  primary  synovial  cases  only  a  trifle 
higher,  namely,  36  per  cent.    Among  907  cases  compiled  by  Hahn  from 

Fig.  494. 


Tuberculous  sequestrum  of  the  tibia.     (Kiinig.) 


various  statistics  (Audry,  Konig,  Mondan,  Munch,  Spengler,  Vallas) 
and  the  material  of  v.  B runs'  clinic  there  was  31  per  cent,  of  primary 
synovial  tuberculosis  and  68.7  per  cent,  of  primary  osseous  tuberculosis. 
In  74  cases  the  origin  was  indefinite. 

If  the  process  spreads  beyond  the  joint,  abscesses  and  fistulas  are 
found  most  frequently  at  the  outer  side  of  the  extensor  tendons,  less  so 
below  the  malleoli  or  at  either  side  of  the  tendo  Achillis.  The  suppu- 
ration may  extend  along  the  tendon-sheaths  and  perforate  outward  at 
some  distance.  The  sheaths  behind  the  malleoli  are  involved  somewhat 
more  frequently  than  those  in  front. 

Symptoms. — The  first  symptom  of  tuberculosis  of  the  ankle-joint  is 
the  effusion  ("hydrops  of  the  joint ").    At  the  onset  there  is  a  soft  swelling 


788  DISEASES  OF  THE  ANKLE  AND  FOOT. 

of  the  synovialis  with  some  pain  in  the  joint,  producing  a  slight  limp; 
this  swelling  appears  first  at  the  sides  of  the  extensor  tendons,  later 
under  the  malleoli  and  behind;  it  varies,  however,  with  the  position  of 
the  osseous  focus. 

The  joint  is  usually  extended,  adducted,  and  inverted  slightly,  but 
movable,  later  becoming  more  fixed.  If  the  mediotarsal  joint  is  involved, 
the  foot  is  often  adducted  and  inverted  at  an  early  period.  There  is 
rarely  any  great  displacement  of  the  joint-surfaces  upon  each  other,  as 
the  astragalus  is  held  firmly  between  the  malleoli;  slight  lateral  and 
sagittal  mobility  is  possible  if  the  ligaments  and  bones  are  destroyed. 

The  pain  on  motion  and  tenderness  are  two  of  the  first  symptoms. 
They  may  be  very  severe,  or  slight  even  when  the  joint  is  greatly 
swollen.  Fever  may  be  absent  as  in  all  cases  of  tuberculosis  of  the 
joints,  and  slight  in  connection  with  suppuration  unless  phlegmon 
occurs  or  the  limb  is  moved  more  actively. 

Diagnosis. — The  differentiation  of  tuberculous  from  rheumatic  or 
syphilitic  joint,  the  joint  of  long-standing  gonorrhceal  arthritis,  the 
swelling  of  painful  flat-foot,  and  the  rarer  acute  inflammations  or  central 
tumors  of  the  bones,  will  depend  chiefly  on  the  history  and  general  point 
of  view.  Tuberculosis  of  the  tendon-sheaths  is  usually  recognizable  by 
the  position  and  irregular  outline  of  the  swelling,  which  does  not  sur- 
round the  joint.  If  the  two  conditions  are  coexistent,  it  may  be  difficult 
to  determine  whether  we  are  dealing  with  the  one  or  the  other,  or  both. 
It  is  also  difficult  to  detect  whether  the  disease  has  spread  to  the  cal- 
caneo-astragaloid  joint,  that  is,  whether  both  or  the  upper  or  the  lower 
of  the  joints  of  the  astragalus  are  affected.  If  the  calcaneo-astragaloid 
joint  alone  is  affected,  the  swelling  lies  chiefly  below  the  malleoli,  passing. 
over  the  upper  part  of  the  calcaneum;  if  the  tibiotarsal  joint  is  simul- 
taneously involved,  swelling  is  also  present  around  and  in  front  of  the 
malleoli. 

The  astragalus,  of  which  the  body  is  more  often  diseased  than  the 
neck,  is  supposed  to  give  characteristic  localized  swelling  and  pain  at 
the  outset,  but  as  one  of  its  joints — most  frequently  the  tibiotarsal — is 
usually  involved  soon  after  or  simultaneously,  the  diagnosis  is  uncertain 
except  where  all  three  of  its  joints  are  involved  at  the  same  time.  In 
170  cases  of  tuberculosis  of  the  astragalus  in  v.  Brains'  clinic  the  ankle- 
joint  was  intact  in  only  8,  and  in  these  the  focus  was  in  the  neck,  the 
head,  or  the  under  surface  of  the  body.     (Halm.) 

The  calcaneum  has  a  unique  position.  It  is  the  most  frequent  site 
of  tuberculosis  of  all  the  tarsal  bones,  and  is  apt  to  contain  large  sequestra. 
The  foci  may  be  situated  below  and  behind  the  sinus  tarsi  (Fig.  41).")) 
or  in  the  posterior  process  and  spread  forward,  especially  in  children; 
or  behind,  under  the  insertion  of  the  tendo  Achillis  and  perforate  back- 
ward; or  there  may  be  a  diffuse  caseous  degeneration  or  almost  total 
sequestration  of  the  bone.  In  the  majority  of  cases  the  process  is 
confined  to  the  bone  without  involving  the  joint.  (Mondan  gives  26  cases 
of  joint  involvement  in  40,  and  in  v.  Brims'  clinic  there  were  87  in  200  of 
tuberculosis  of  the  calcaneum.)    Perforation  takes  place  most  frequently 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES  OF  THE  FOOT.      789 

outward  or  outward  and  downward,  much  less  so  inward  or  backward. 
The  calcaneo-astragaloid  joint  is  the  one  most  often  concerned  in  the 
few  cases  of  joint-involvement  (according  to  Mondan  only  14  cases  in 
40);  the  tnediotarsal  is  next  in  frequency.  Abscesses  and  sinuses  arc 
then  more  frequently  met  with  on  the  inner  side  of  the  foot  or  at  the 
sides  of  the  tendo  Achillis.  The  calcaneocuboid  joint  is  seldom  attacked. 
If  the  soft  parts  arc  involved,  the  tendon-sheaths  of   the  peronei  are 

Fig.  49.5. 


Fig.  496. 


Tuberculous  foci  in  the  os  calcis.    (Finotti.) 

more  apt  to  be  affected  than  the  flexors  on  the  inner  side,  but  in  the 
latter  case  the  process  is  liable  to  spread  into  the  sole  and  become  more 
serious. 

The  symptoms  of  tuberculosis  of  the  calcaneum  are  very  characteristic 
in  many  cases.  The  surrounding  soft  parts  are  swollen  and  the  bone 
itself  is  thickened,  suggesting  a  tumor  or  osteomyelitic  necrosis.  The 
swelling  lies  below  the  malleoli.  The  more  it  is  limited  to  the  heel,  the 
easier  is  the  diagnosis  of  disease  of  the  calcaneum  alone.  In  such  cases 
Konig  has  more  frequently  found  the  sinuses  leading  to  the  tuberosity 
and  a  diseased  area  near  the  tendo  Achillis,  whereas  Wiesinger  has 


790  DISEASES  OF  THE  ANKLE  AND  FOOT. 

found  the  bursa  achillea  involved.  We  have  rarely  seen  this  condition 
without  joint-involvement.  If  the  calcaneo-astragaloid  joint  is  involved, 
the  swelling  extends  higher  toward  the  malleoli  and  eversion  and  inver- 
sion are  painful.  A  positive  diagnosis  of  disease  of  this  joint  is  hardly 
possible,  however. 

In  the  small  anterior  tarsal  bones  and  their  joints  the  disease  is  more 
apt  to  be  limited  to  the  inner  or  outer  side  of  the  foot  if  the  scaphoid 
or  cuboid  alone  is  affected.  But  generally  the  process  in  the  anterior 
tarsals  is  distinguished  by  the  fact  that  it  extends  rapidly  over  the  area 
between  Chopart's  and  Lisfranc's  joints,  often  attacking  the  anterior 
articular  surfaces  of  the  astragalus  and  calcaneum;  and  in  front,  the 
bases  of  the  four  last  metatarsals.  The  disease  may  start  in  one  of  the 
latter.  The  first  metatarsal  and  its  articulation  with  the  first  cuneiform 
is  seldom  involved  unless  this  joint  communicates  with  the  others,  but 
it  is  often  diseased  alone.  The  two  synovial  sacs  situated  between  the 
four  last  metatarsals  and  the  tarsus  are  less  distinctly  shut  off  from 
each  other,  so  that  the  process  often  spreads  rapidly  across  Lisfranc's 
joint.  It  also  meets  with  little  resistance  in  passing  to  or  from  the 
tarsus. 

As  the  swelling  spreads  rapidly  and  uniformly  over  the  foot  between 
the  mediotarsal  and  tarsometatarsal  joints,  it  is  impossible  to  determine 
the  site  of  the  primary  focus  after  the  disease  is  advanced.  If  suppu- 
ration occurs,  it  is  apt  to  perforate  on  the  dorsum  or  at  the  sides.  Ab- 
scesses in  the  sole  usually  attain  considerable  size  under  the  tense  fascia 
before  perforating.  In  severe  cases  the  swelling  is  spindle-shaped 
between  Chopart's  and  Lisfranc's  joints,  often  with  many  fistulas.  The 
foot  is  extended;  the  front  part  of  the  foot  is  extended,  adducted,  and 
often  also  inverted. 

In  the  metatarsals  and  toes  tuberculosis  usually  appears  in  the  form 
of  spina  ventosa  in  children,  as  in  the  metacarpus  and  fingers.  The 
disease  is  often  multiple.  In  adults  the  joints  and  articular  ends  of  the 
bones  are  more  frequently  affected,  usually  the  metatarsophalangeal 
joint  and  metatarsal  of  the  great  toe,  less  frequently  the  fifth  metatarsal 
or  the  other  bones  and  joints. 

The  frequency  of  tuberculosis  in  the  bones  of  the  foot  is  given  by 
Halm  from  the  statistics  of  1231  cases  as  follows:  calcaneum,  26  per 
cent.;  astragalus,  24  per  cent.;  cuboid,  13  per  cent.;  scaphoid,  9 
per  cent.;  cuneiforms,  9  per  cent.;  metatarsals,  9  per  cent.;  malleoli, 
8  per  cent.;  and  phalanges,  2  per  cent. 

Treatment. — The  treatment  of  tuberculosis  of  the  tarsus  and  tibio- 
tarsal  joint  should  be  conservative  at  the  beginning  of  the  disease,  except 
where  there  is  positive  evidence  of  the  existence  of  a  large  osseous  focus, 
as,  for  example,  in  many  cases  of  tuberculosis  of  the  calcaneum.  Few 
surgeons  would  advise  operating  in  every  case  involving  the  ankle-joint 
as  soon  as  the  diagnosis  is  made,  for  a  considerable  number  of  these 
recover  without  operation,  especially  in  youth. 

The  principles  of  conservatism  are  the  same  as  applied  to  tuberculosis 
in  general.    In  the  absence  of  any  great  amount  of  suppuration,  rest  and 


Tl'UKIKTI.nsiS  OF  THE  JOINTS  AND   BONES  OF  THE  FOOT.      791 

fixation  with  moderate  pressure,  and  finally  elevation  when  there  is 
much  swelling,  are  most  effectual.  As  usual,  the  foot  should  be  fixed 
at  a  right  angle  to  the  leg  and  in  the  mid-position  between  eversion  and 
inversion,  the  only  proper  position  in  ease  ankylosis  follows.  A  well- 
fitting  plaster-splint  is  the  best,  though  strip  splints  or  removable  fixation 
apparatus  may  be  used.  Rest  and  immobilization  of  the  joint  are  best 
assured  by  the  recumbent  position.  Children  do  well  in  bed,  even  for 
a  long  period.  Hut  some  do  better  to  be  about,  as  in  the  case  of  adults, 
as  soon  as  possible.  If  the  ordinary  fixation  splints  and  apparatus  are 
worn  crutches  have  to  be  used,  as  the  former  do  not  take  the  weight 
off  of  the  ankle-joint.  So  the  ambulant  splints  are  better  which  make 
walking  possible  without  encumbering  or  disturbing  the  foot.  This  can 
be  accomplished  by  means  of  the  simple  plaster-splint  if  it  is  supported 
firmly  against  the  tuberosities  of  the  tibia;  the  sole  of  the  foot  is  well 
padded  with  cotton,  or,  better,  an  iron  foot-brace  is  incorporated  in  the 
plaster,  extending  half  an  inch  or  more  below  the  foot,  and  the  other 
foot  raised  with  a  thick  sole.  Of  the  removable  apparatus,  the  best  are 
those  made  in  two  parts,  the  lower  like  a  high,  tightly  fitting  laced  shoe, 
and  the  upper  having  a  brace  to  bear  against  the  tuberosities  of  the 
tibia  or  the  tuber  ischii. 

In  addition  injections  of  iodoform  glycerin,  etc.,  may  be  used  at  the 
same  time.  They  seem  to  act  favorably  in  the  foot.  The  ankle-joint 
can  be  injected  at  the  sides  of  the  extensor  tendons,  and  other  joints 
and  abscesses  at  appropriate  points.  In  regard  to  other  methods,  such 
as  passive  congestion,  which  could  easily  be  combined  with  ambulant 
treatment,  the  author  has  had  no  experience. 

When  and  how  long  to  attempt  conservative  treatment  is  a  difficult 
question.  In  children  even  suppurative  and  fistulous  tuberculosis  occa- 
sionally heals  under  fixation  and  iodoform  glycerin  injections  without 
operation  or  possibly  after  scraping  out  or  opening  up  the  fistulas  and 
abscesses.  If  the  child's  general  condition  is  good,  the  author  advises 
conservatism.  Immediate  operation  is  only  indicated  in  the  cases  of 
profuse  suppuration,  often  accompanied  by  fever,  and  especially  in 
those  in  which  large  osseous  foci  are  suspected  or  demonstrated,  as 
in  numerous  cases  of  tuberculosis  of  the  calcaneum. 

If  after  several  wreeks  of  conservative  treatment  no  improvement 
occurs,  the  general  condition  becomes  worse,  or  evidence  of  tuberculosis 
appears  in  the  inner  organs,  operation  is  necessary.  Maas  in  Konig's 
clinic  advises  operation  after  the  treatment  has  been  tried  for  two  months; 
this  applies  to  children.  In  adults  the  prospect  of  recovery  by  con- 
servative treatment  is  slight,  so  that  the  appearance  of  suppuration  is 
positive  indication  for  operation. 

In  children  the  abscesses  and  sinuses  may  be  incised  and  scraped  out 
successfully;  but  in  adults  these  procedures  are  often  followed  by  exacer- 
bation and  rapid  involvement  of  the  adjacent  joints,  tendon-sheaths,  and 
soft  parts.  Therefore  it  is  imperative  in  adults  to  remove  thoroughly  all 
tuberculous  tissue  by  free  exposure  and  careful  dissection  of  the  diseased 
area.     Arthrectomy,  resection,  or  even  amputation  may  be  necessary. 


792  DISEASES  OF  THE  ANKLE  AND  FOOT. 

There  is  not  yet  any  unanimity  of  opinion  as  to  the  time  for  resection 
or  amputation.  In  general  the  indications  for  resection  have  been 
greatly  extended  in  the  last  ten  or  twenty  years,  and  the  results  of  resec- 
tion are  much  better  than  formerly.  This  is  mainly  due  to  the  fact  that 
we  no  longer  dread  the  bad  functional  results  of  extensive  resection  that 
previously  often  made  surgeons  hesitate  to  remove  the  tuberculous 
tissues  thoroughly.  We  know  to-day  that  even  after  very  extensive 
resection  for  severe  cases  of  tuberculosis  recovery  is  more  rapid  and  the 
usefulness  of  the  resulting  foot  is  satisfactory,  in  fact  even  better  than 
after  partial  amputation.  The  most  radical  methods,  which  secure  the 
removal  of  all  diseased  tissues  and  thereby  prevent  recurrence,  seem  to  us 
to  be  the  best,  for  they  ensure  the  quickest  recovery  and  allow  the  patient 
to  be  about  in  the  least  time.  The  latter  consideration  is  important,  as  the 
danger  of  recurrence,  especially  for  older  patients,  lies  in  the  long  period 
of  convalescence  and  the  decrease  in  general  strength  thereby  entailed. 
The  question  as  to  resection  or  amputation  is  decided  somewhat  by  the 
local  condition,  but  more  particularly  by  the  strength  of  the  patient  to 
endure  a  long  period  of  convalescence.  This  depends  upon  the  general 
condition,  and  especially  upon  the  age  of  the  patient.  Isler  found  that  the 
mortality  of  resection  up  to  the  fifteenth  year  was  5  per  cent.,  from  the 
twentieth  to  the  twenty-fifth  year  10  per  cent.,  and  later  19  per  cent.; 
the  younger  the  patient  the  better  was  the  functional  result.  As  to 
resection  or  amputation  in  general,  advanced  age  is  an  indication  for 
amputation.  Rapidly  progressing  or  extensive  tuberculosis  of  the  lungs 
or  other  organs,  amyloid  degeneration,  and  great  weakness  are  counter- 
indications  to  resection,  although  even  with  these  conditions  the  results 
in  younger  individuals  are  occasionally  unexpectedly  favorable.  The 
various  methods  of  operation  will  be  found  under  operations  on  the  foot; 
only  the  more  important  will  be  discussed  here,  and  those  applicable  to 
certain  special  regions  of  the  foot. 

The  operative  treatment  of  tuberculosis  of  the  ankle-joint  has  nothing 
to  distinguish  it  from  the  treatment  of  disease  of  the  two  posterior  tarsal 
bones,  as  the  joint  is  almost  always  involved  with  the  latter,  except  in 
the  cases  of  primary  tuberculosis  of  the  calcaneum.  The  old  resection 
methods  of  Bourgery  and  v.  Langenbeck  are  not  suitable,  as  they  do 
not  give  a  good  view  of  the  diseased  area,  sacrifice  too  much  bone  from 
the  leg,  and  endanger  the  usefulness  of  the  foot,  for  in  tuberculosis  the 
growth  of  new  bone  often  remains  insufficient.  Konig's  method  gives 
a  better  view  of  the  joint  than  most  of  the  other  methods  with  anterior 
or  posterior  longitudinal  incisions,  unless  one  removes  the  astragalus 
according  to  Yogt  and  Oilier;  it  also  preserves  the  malleoli,  but  does 
not  facilitate  the  removal  of  the  synovialis  behind.  For  this  reason 
v.  Brims  adds  two  longitudinal  incisions  at  either  side  of  the  tendo 
Achillis.  Riedel's  modification  of  Konig's  method  is  also  valuable; 
also  the  curved  outer  incision  of  Kocher  and  Lauenstein.  By  the  latter 
method  the  joint  can  be  dislocated  and  the  capsule  exposed  throughout 
and  excised  without  "resecting  any  bone.  If  the  process  extends  on  the 
inner  side  of  the  foot  toward  the  astragalonavicular  joint  or  involves 


TUBERCULOSIS  OF  THE  JOINTS  AND  BONES  OF  THE  FOOT.     793 

the  soft  parts  and  tendons,  Konig's  method  is  better,  or  the  anterior 
transverse  incision  of  Heyfeldcr  and  Sedillot  recommended  by  I  Inter. 
Honssev's  anterior  curved  or  flap  incision  can  be  used  to  even  better 
advantage,  particularly  if  the  process  extends  over  the  front  of  the  tarsus, 
as  it  gives  a  good  view  of  the  ankle-joint,  and,  if  necessary,  the  entire 
tarsus.  The  function  of  the  tendons  is  also  more  readily  restored  the 
farther  forward  they  are  divided,  even  when  they  are  not  sutured.  The 
wound  can  therefore  be  packed  with  iodoform  gauze  for  a  long  time.  In 
general,  however,  in  view  of  their  being  the  least  conservative,  the  anterior 
curved  and  transverse  incisions  should  be  reserved  for  very  severe  cases. 

As  to  the  advisability  of  attempting  to  procure  a  movable  but  stable 
joint  after  arthrectomy  or  resection — this  is  undoubtedly  the  more  ideal 
result  and  one  which  is  most  feasible  if  the  malleoli  are  preserved.  But 
the  possibility  of  recurrence  is  greater  in  a  movable  joint,  so  that  in  the 
author's  experience  ankylosis  is  in  general  better  assurance  against  recur- 
rence and  more  conducive  to  definite  recovery.  Among  102  resections  in 
Konig's  clinic  recorded  by  Maas:  of  11  operated  upon  by  v.  Langenbeck's 
method,  only  1  case  recovered  with  a  useful  joint;  of  87  operated  on  by 
Konig's  method,  in  48  of  which  the  astragalus  was  removed,  42  were 
examined  later;  they  all  had  a  useful  joint  without  looseness  or  deformity 
of  the  foot.  The  shortening  was  3^  to  Sh  inches  in  contrast  to  5|  inches 
by  v.  Langenbeck's  method. 

If  the  process  is  confined  chiefly  to  the  posterior  part  of  the  tibiotarsal 
or  the  calcaneo-astragaloid  joint  and  spreads  out  at  the  sides  of  the 
tendo  Achillis,  the  methods  of  Szabanejew  and  Bogdanik  are  best.  The 
astragalus  can  also  be  removed  by  these  methods.  If  the  disease  is 
limited  to  the  posterior  calcaneo-astragaloid  joint,  Oilier  advises  a 
bilateral  V-shaped  flap-incision  with  base  above,  one  side  of  the  V  in 
front  of  the  tendo  Achillis,  the  other  parallel  to  the  inner  and  outer 
borders,  respectively,  of  the  foot. 

Foci  in  the  calcaneum  are  best  removed  from  the  outer  side  even  when 
the  fistulas  open  on  the  inner  side.  In  children  the  focus  can  be  exposed 
through  a  horizontal  incision  and  scraped  or  chiselled  out.  The  cavity 
gradually  fills  in  of  itself.  If  the  foci  are  very  large  it  is  better,  espe- 
cially in  older  people,  to  remove  the  lateral  wall  of  the  cavity  and 
implant  the  soft  parts.  For  this  purpose,  a  curved  or  angular  incision 
on  the  outer  side  is  best,  as  employed  for  removal  of  the  calcaneum.  If 
in  addition  the  astragalus  and  the  calcaneo-astragaloid  and  tibiotarsal 
joints  are  diseased,  both  bones  may  demand  excision  (posterior  tar- 
sectomy).  Often  the  under  surface  of  the  calcaneum  is  intact  (v.  Bruns, 
Kuttner),  for  example,  when  the  calcaneum  is  involved  secondarily 
from  the  astragalus  or  the  focus  lies  nearer  the  upper  surface.  In  this 
case  the  lower  surface  should  be  preserved ;  v%  Bruns'  resectio  tibiocal- 
canea  may  be  used  with  advantage.  In  all  resections  of  the  posterior 
tarsal  bones  the  integrity  of  the  sole  of  the  foot  should  be  preserved  if 
possible.  The  osteoplastic  resection  of  Wladimiroff  and  v.  Mikulicz  is 
necessary  only  when  the  soft  parts  and  skin  of  the  heel  are  destroyed  or 
filled  with  fistulas. 


794  DISEASES  OF  THE  ANKLE  AXD  FOOT. 

In  the  anterior  part  of  the  tarsus,  if  the  disease  is  limited  to  single 
bones  and  joints,  as,  for  example,  to  the  cuboid,  first  cuneiform,  and 
first  tarsometatarsal  joint,  or  to  the  scaphoid,  partial  resection  may  be 
sufficient,  and  can  be  performed  through  a  longitudinal  incision  at  the 
side  or  on  the  dorsum  of  the  foot.  This  is  advisable,  however,  only  in 
youthful  patients.  If  the  process  is  more  extensive,  even  though  it  does 
not  involve  the  whole  width  of  the  foot,  it  is  better  to  resect  the  entire 
transverse  portion  (anterior  tarsectomy).  This  is  especially  advisable 
in  older  individuals,  because  the  growth  of  new  bone  is  inadequate  to 
prevent  troublesome  deviations  of  the  foot,  furthermore  because  radical 
removal  of  the  diseased  tissue  is  urgent. 

The  metatarsals  and  toes  are  less  essential  parts  of  the  foot,  and  may 
be  removed  more  radically,  for,  if  preserved,  the  resulting  deviation 
and  contracture  are  liable  to  be  troublesome  later.  In  children  expe- 
rience has  shown  that  spina  ventosa  has  been  little  influenced  by 
injection  of  iodoform.  Hence  if  suppuration  occurs,  operation  is  indis- 
pensable. In  adults  the  conditions  are  even  less  favorable,  so  that 
operation  is  indicated  at  the  outset.  If  the  tarsometatarsal  joints 
become  involved,  they  should  be  resected,  possibly  with  the  metatarsals, 
or  in  children  scraped  out  with  a  sharp  spoon.  If  the  epiphyseal  lines 
of  the  toes  are  destroyed,  it  is  better  to  remove  the  toes,  except  in  the 
case  of  the  great  toe,  which  should  always  be  preserved  if  possible.  In 
older  patients  one  has  to  choose  between  leaving  part  of  the  front  por- 
tion of  the  foot,  with  the  possibility  of  recurrence,  and  amputation. 

Tuberculosis  of  the  metatarsophalangeal  and  interphalangeal  joints 
in  children  should  be  subjected  if  slight  to  thorough  scraping  or  resec- 
tion, otherwise  amputation  or  exarticulation  is  preferable.  In  adults, 
amputation  is  almost  always  better,  except  again  in  the  case  of  the  great 
toe,  whose  metatarsophalangeal  joint  is  a  spot  of  choice  for  tuberculosis; 
here  resection  should  always  be  tried  at  first  unless  rendered  impossible 
by  extension  of  the  disease,  above  all  by  the  general  condition  and 
advanced  age  of  the  patient. 

Widely  as  we  are  able  to  apply  conservatism  in  the  operative  treat- 
ment of  tuberculosis  of  the  foot,  there  always  remains  a  considerable 
number  of  cases  in  which  conservatism  fails  or  is  contraindicated  by 
the  extent  of  the  process  or  the  advanced  age  or  poor  condition  of  the 
patient.  Amputation  is  then  necessary.  No  rules  can  be  given  as  to 
the  choice  of  methods  of  amputation  or  exarticulation.  One  thing  is 
important:  to  operate  in  sound  tissues  and  not  be  too  sparing  of  a 
portion  of  foot  or  leg.  In  these  cases  everything  depends  upon  the 
prevention  of  recurrence  and  upon  rapid  recovery. 

In  not  a  few  very  extensive  cases  of  tuberculosis  of  the  foot  resection 
has  been  made  to  include  portions  of  the  anterior  section  of  the  tarsus 
beside  the  two  posterior  tarsals,  or  the  entire  tarsus  with  the  exception 
of  the  lower  surface  of  the  calcaneum.  In  fact,  the  tarsus,  with  or 
without  the  articular  surfaces  of  the  tibia  and  fibula,  has  been  removed. 
Yet  the  use  of  the  foot  was  often  very  good.  Various  incisions  were 
used;  long  inner  or  outer  longitudinal,  or  transverse.     The  most  prac- 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        795 

tical  incision  for  such  atypical  resections  is  a  large  anterior  flap-incision. 
The  usefulness  of  the  fool  was  largely  due  to  new  hone  formation.  As 
stated  above,  it  is  therefore  advantageous  to  preserve  pari  of  the  cal- 
caneum,  either  the  periosteum,  tuberosity,  or  lower  surface,  although 
even  without  it  the  fool  can  be  useful. 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 

Contractures  and  the  deformities  which  result  from  them  are  fre- 
quently met  with  in  the  foot;  they  are  of  greater  significance  here  than 
in  any  other  part  of  the  body.  While  in  the  other  joints  the  contrac- 
tures of  arthritic  origin — that  is,  due  to  inflammatory  changes  in  the 
joint — are  in  the  majority,  their  importance  is  slight  in  the  foot  com- 
pared to  those  due  to  a  number  of  other  causes. 

A  large  group  of  deformities  of  the  foot  are  congenital,  the  result  of 
faulty  embryonal  construction,  or  of  external  forces  producing  faulty 
position  and  development  in  utero  of  the  normally  constructed  foot. 
Congenital  club-foot  is  an  example  of  this  type  of  deformity. 

The  other  main  group  consists  of  those  forms  acquired  later  in  life. 
Among  these  belong  the  cases  of  arthrogenous  contracture  and  ankylosis 
which  are  followed  by  other  contractures  due  to  cicatricial  contraction 
of  the  soft  parts,  for  example,  the  talipes  equinus  caused  by  cicatricial 
retraction  of  the  calf  muscles.  Also  the  deformities  due  to  over-  or 
faulty  weighting  of  the  foot  and  the  wearing  of  improper  shoes.  Flat- 
foot  is  the  most  common  example  of  this  type.  There  is  also  a  large 
and  important  class  of  contractures  due  to  neurotrophic  disturbances. 
Before  describing  the  various  forms  of  contractures  it  will  save  repetition 
to  discuss  paralytic  contractures  and  the  aims  of  treatment  in  the  differ- 
ent varieties  of  deformities  of  the  foot. 

Mode  of  Origin  of  Paralytic  Contractures. — The  development  of  para- 
lytic contractures  has  been  explained  for  a  long  time  by  Delpech's 
theory  of  antagonistic  muscular  action.  When  one  group  of  muscles 
is  paralyzed,  the  healthy  antagonists  by  reason  of  their  muscular  tone 
draw  the  limb  to  their  side  and  so  into  a  contracture  position.  This 
theory  was  opposed  by  Werner  in  1851,  but  first  disproved  satisfac- 
torily by  Hiiter  and  v.  Volkmann.  They  showed  that  contracture  fol- 
lowed paralysis  of  entire  as  well  as  single  groups  of  muscles,  and  that  it 
was  due  essentially  to  mechanical  influences,  the  weight  of  the  foot,  and 
encumbrance  of  the  same.  They  went  too  far,  however,  in  entirely 
disregarding  the  contraction  and  elasticity  of  the  muscles.  Seeligmuller 
recognized  these  factors,  so  the  explanation  of  contracture  is  now  antag- 
onism and  mechanical  action.  The  healthy  muscles  in  contracting 
give  the  limb  a  position  which  is  maintained  unless  mechanical  factors 
act  upon  the  foot,  as  the  paralyzed  muscles  are  not  able  to  combat  the 
shortening  of  the  sound  muscles  which  is  at  first  voluntary,  but  becomes 
permanent  by  reason  of  their  inherent  elasticity.  This  leads  to  shrinkage 
of  the  sound  muscles.     As  a  rule  external  mechanical  forces  act  upon 


796  DISEASES  OF  THE  ANKLE  AND  FOOT. 

the  foot  in  the  same  or  opposite  direction  to  the  action  of  the  healthy 
muscles.  In  the  latter  case  the  mechanical  action  is  usually  stronger 
than  that  of  the  sound   muscles. 

In  order  to  make  clear  the  influence  of  gravity  and  encumbrance 
upon  the  foot,  which  is  of  such  importance  in  order  to  understand  all 
other  non-paralytic  contractures,  we  will  assume  that  all  the  muscles 
are  paralyzed.  The  weight  of  the  foot  then  comes  into  play  when  the 
foot  is  not  used  in  walking  or  standing,  as  has  been  shown  especially  by 
Hiiter.  In  the  recumbent  position,  or  with  the  foot  dependent,  as  in 
sitting  or  walking  with  crutches  with  the  limb  drawn  up,  the  part  of  the 
foot  in  front  of  the  rotary  axis  of  the  ankle-joint  is  heavier  than  the 
shorter  part  behind,  so  the  front  drops  and  the  heel  rises  (talipes  equinus). 
But  the  disposition  of  the  weight  of  the  foot  and  the  axis  of  motion  in  the 
mediotarsal  joint  combine  also  to  adduct  and  invert  the  foot,  so  the 
foot  is  almost  always  in  a  position  of  combined  talipes  equinus  and 
varus — that  is,  paralytic  talipes  equinovarus. 

At  the  outset  the  foot  can  be  easily  carried  over  from  this  position  to 
the  opposite  one,  but  unless  the  plantar  flexors  are  opposed  by  mechan- 
ical action,  they  gradually  shrink  while  the  dorsal  flexors  become 
stretched.  In  the  same  way  the  ligaments  and  fascia  shrink  on  the 
concave  surface  and  stretch  on  the  convexity.  Thus  the  abnormal 
position  becomes  a  fixed  one  and  the  contracture  is  complete.  Finally, 
changes  also  take  place  in  the  bones  and  joints;  the  cartilages  are  apt  to 
disappear  where  they  are  no  longer  in  contact  and  new  cartilage  forms 
on  the  opposite  side  of  the  joints,  so  that  the  latter  become  shifted  or 
even  new  joints  are  formed;  the  form  and  structure  of  the  bones  change 
to  meet  the  demands  of  altered  pressure.  All  these  factors  further 
increase  and  fix  the  contracture. 

The  above  results  of  the  action  of  the  weight  of  the  foot  occur  not  only 
in  paralysis  of  the  foot,  but  at  all  times  when  the  muscles  which  influ- 
ence the  position  of  the  foot  are  thrown  out  of  action  voluntarily  or 
otherwise.  For  example,  in  injuries  or  inflammations  of  the  bones, 
joints,  muscles,  or  tendons  about  the  ankle,  if  the  muscles  are  weakened 
or  their  activity  is  arrested,  or  if  the  patient  prevents  their  action  to 
avoid  pain,  or  is  kept  in  the  recumbent  position  for  a  long  time  by  severe 
and  weakening  illness.  The  development  of  a  contracture  is  then  favored 
by  still  other  mechanical  causes,  such  as  the  weight  of  the  bed-coverings, 
etc.  The  significance  of  the  peculiar  disposition  of  the  weight  of  the 
foot  therefore  exceeds  that  of  the  paralytic  contracture,  and  should 
always  be  thought  of  in  connection  with  all  of  the  above-mentioned 
forms  of  disease  of  the  foot.  Unfortunately  it  is  often  impossible, 
although  so  simple,  to  prevent  the  development  of  a  contracture  by 
appropriate  exercises  or  splints.  So  many  a  patient  suffers  unneces- 
sarily for  the  carelessness  of  his  physician  in  being  temporarily  or  even 
permanently  disabled. 

Under  certain  conditions  the  action  of  gravity  upon  the  completely 
paralyzed  foot  is  opposed  by  bearing  the  weight  upon  it.  When  stand- 
ing or  walking  the  weight  of  the  body  upon  the  foot  causes  it  to  become 


COXTJtACTl'RES  AM)  DEFORMITIES  OF  THE  FOOT.         797 

flexed  and  at  the  same  time  abducted  or  everted  in  direct  opposition  to 
the  action  of  gravity.  As  the  plantar  flexors  and  invertors  arc  par- 
alyzed, eversioD  and  dorsal  flexion  are  only  checked  by  the  bones  and 
ligaments.  But  these  gradually  give  way  and  the  foot  becomes  over- 
flexed,  everted,  and  abducted — that  is,  in  the  talipes  calcaneovalgus  posi- 
tion. Hut  as  the  foot  is  extended  by  the  action  of  gravity  every  time  it 
is  raised  from  the  ground  and  when  the  patient  is  lying  down,  the  result 
is  an  abnormally  loose  ankle-joint  (flail-foot).  If,  however,  as  is  often 
the  ease,  a  certain  degree  of  talipes  equinovarus  contracture  develops 
before  the  foot  is  used,  then  the  patient  cannot  place  the  sole  flatly  in 
walking,  but  bears  the  weight  on  the  outer  edge  of  the  foot.  This 
causes  the  foot  to  become  more  and  more  adducted  and  inverted  in  the 
same  way  that  it  is  acted  upon  by  the  force  of  gravity,  until  a  high- 
grade  talipes  equinovarus  develops. 

Assuming  now  that  one  group  of  muscles  is  paralyzed,  for  example, 
the  dorsal  flexors,  while  the  antagonists,  the  plantar-flexors,  are  still 
active :  with  the  first  attempt  to  move  the  foot  it  will  be  extended  by  the 
plantar  flexors  and  remain  so  under  the  influence  of  gravity  so  long  as 
the  patient  is  recumbent  or  the  foot  hangs  down.  Thus  muscular 
action  and  gravity  work  together  and  a  contracture  will  develop  early.  If 
the  foot  is  used  in  walking,  this  action  may  be  combated;  but  usually 
the  encumbrance  increases  the  equinovarus  contracture,  as  the  latter 
often  exists  before  the  patient  begins  to  walk. 

When  the  plantar  flexors  are  paralyzed  and  the  dorsal  flexors  are 
intact,  as  Seeligmuller  has  shown,  the  foot  becomes  flexed  and  may  be 
fixed  in  this  position  (talipes  calcaneus)  as  the  result  of  the  shortening 
of  the  dorsal  flexors  unless  the  action  of  the  plantar  flexors  is  effected  by 
mechanical  forces.  This  is  usually  what  happens,  the  action  of  gravity 
extending  the  foot  as  soon  as  the  dorsal  flexors  are  relaxed.  A  talipes 
calcaneus  contracture  seldom  develops  if  the  patient  does  not  walk  or 
stand.  As  soon  as  the  patient  does  walk  the  weight  of  the  body  forces 
the  foot  into  the  talipes  calcaneovalgus  position.  As  in  total  paralysis 
of  the  foot,  this  position  seldom  becomes  fixed,  however,  because  the 
foot  is  always  extended  by  gravity  when  suspended  or  in  the  recumbent 
position. 

These  examples  may  suffice  to  explain  the  varying  action  of  the  forces 
working  upon  the  paralyzed  foot  to  produce  contractures  or  not,  as  the 
case  may  be.  We  shall  have  occasion  later  to  discuss  many  modifica- 
tions of  the  contractures  mentioned  and  combinations  of  the  same;  also 
the  action  of  the  various  mechanical  forces  and  the  individual  types  of 
paralysis. 

Treatment  of  Contractures. — The  aim  of  treatment  in  the  different 
contractures  will  vary  according  to  the  mode  of  origin  of  the  deformity 
and  the  causes  of  the  impaired  motion.  In  a  large  number  of  cases, 
in  which  the  motor  apparatus  is  essentially  intact  in  spite  of  the  exist- 
ence of  contracture,  we  are  very  often  more  or  less  successful  in  restor- 
ing the  full  use  of  the  limb  by  operative  or  orthopaedic  measures.  In 
others  we  have  to  be  satisfied  with  partial  results.     To  the  latter  class 


798 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


belong  the  large  group  of  paralytic  contractures.  Overcoming  the  con- 
tracture does  not  mean  that  the  patient  is  cured,  for  it  returns  gradually 
as  soon  as  treatment  ceases.  So  throughout  the  rest  of  their  lives  the 
patients  have  to  wear  orthopaedic  apparatus  replacing  the  action  of 
the  paralyzed  muscles  by  means  of  elastic  bands  or  springs,  or  at  least 
preventing  the  evil  results  of  the  functional  loss. 


As  this  method  of  treatment  is  always  troublesome  and  a  trial  and 
pecuniary  burden  to  the  patient,  especially  among  the  poorer  classes, 
the  effort  to  supplant  it  or  make  it  less  burdensome  by  other  procedures 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        799 

is  justifiable.  There  are  two  modern  operative  methods  which  have 
this  purpose  in  view,  namely,  arthrodesis  and  tendon  transplantation. 
By  means  of  arthrodesis  the  contracted  or  abnormally  movable  foot  is 
transformed  into  a  still'  natural  stilt;  by  tendon  transplantation  the 
<  Uoit  is  made  to  replace  the  action  of  the  paralyzed  muscles  by  group- 
ing the  intact  muscles  so  as  to  maintain  the  foot  in  its  normal  position 
and  prevent  contractures  from  developing.  Without  any  question  the 
purpose  of  the  latter  method  is  more  nearly  ideal.  Tendon  transplan- 
tation was  first  employed  by  Nicoladoni  to  overcome  a  pes  calcaneus  due 
to  paralysis  of  the  calf  muscles ;  since  then  the  method  has  been  developed 
by  Drobnik,  Vulpius,  Hoffa,  Lange,  and  others,  and  made  applicable  to 
all  spastic  and  total  paralyses  and  their  sequelae. 

Of  the  various  modifications  of  the  method  the  following  are  most 
useful:  1.  Functional  transfer.  The  healthy  muscle  is  divided  and 
the  proximal  stump  sutured  to  the  paralyzed  muscle  or  its  tendon. 
(Fig.  497.)  As  the  original  function  of  the  muscle  is  thus  destroyed 
the  method  can  be  used  only  when  the  sound  muscle  can  be  dispensed 
with.  2.  Functional  division.  (Fig.  498.)  (a)  The  distal  stump  of  the 
paralyzed  muscle  is  sutured  to  the  sound  muscle,  (b)  A  flap  of  sound 
muscle  is  sutured  to  the  paralyzed  muscle.     This  is  the  better  method. 

Periosteal  tendon  transplantation,  as  proposed  by  Lange,  has  the 
advantage  of  using  only  intact,  healthy  muscle  without  employing  the 

Fig.  499. 


Shortening  tendon  by  "gathering." 

atrophied  tendon.  For  example,  in  paralytic  talipes  varus  with  the 
peronei  paralyzed  and  the  tibialis  anticus  intact,  the  tendon  of  the  latter 
is  split  and  the  outer  half  sutured  to  the  periosteum  of  the  cuboid.  The 
muscle  thus  overcomes  the  pathological  position  and  also  has  a  new 
function.  (J.  Wolff's  osteal  tendon  transplantation  has  no  apparent 
advantage  over  the  above  method.) 

The  plan  of  operation  should  be  worked  out  carefully  in  every  case; 
often  a  long  and  accurate  examination  is  necessary  to  determine  which 
muscles  are  paralyzed  or  weakened,  which  are  active. 

The  electrical  reaction  of  the  muscles  is  indispensable  in  connection 
with  the  test  of  their  active  mobility  for  the  purpose  of  determining 
the  availability  of  the  various  muscles  for  any  plan  of  operation.  In- 
spection of  the  muscles  at  the  time  of  operation  gives  no  definite  infor- 
mation as  to  their  power  of  regeneration.  The  correction  should  always 
be  excessive,  as  the  atrophied  tendons  stretch  in  time. 


800  DISEASES  OF  THE  ANKLE  AXD  FOOT. 

As  a  rule  transplantation  is  combined  with  other  operations  on  the 
tendons  (lengthening  or  shortening).  The  tendon  is  lengthened  best 
by  Bayer's  Z-shaped  section.  Shortening  is  effected  by  dividing  the 
tendon  transversely  and  overlapping  the  stumps,  or  by  Lange's  method 
of  ruffling  the  tendon.  (Fig.  499.)  In  v.  Bergmann's  clinic  the  tendons 
are  sutured  with  sterilized  silk,  the  skin  with  catgut,  and  a  circular 
plaster-splint  applied  and  left  on  for  three  weeks;  later,  massage  and 
exercise.  Tendon  transplantation  is  advisable  only  when  there  is  a  pros- 
pect of  obtaining  a  result  which  makes  any  other  than  very  light  appa- 
ratus unnecessary.  Otherwise,  at  least  among  the  poor,  arthrodesis  is 
preferable.  The  success  of  transplantation  in  many  cases  depends  upon 
long  and  exacting  after-treatment.  The  after-treatment  of  arthrodesis  is 
slight  and  simple. 

Talipes  Varus  [Pes  varus,  equinovarus,  pied  hot  varus,  piede  varo, 
Klumpfuss]. — The  term  talipes  varus  [club-foot  of  the  author]  is  applied 
to  every  faulty  inversion  position  of  the  foot  maintained  under  abnor- 
mal conditions.  (Bessel-Hagen.)  Physiologically  inversion  is  accom- 
panied by  a  certain  amount  of  adduction  and  extension.  In  talipes 
varus  the  physiological  limit  of  adduction  and  extension  of  the  foot 
is  usually  exceeded,  but  as  this  is  not  constant  it  must  be  regarded 
merely  as  an  associated  condition.  In  general,  only  those  deformities 
can  be  designated  as  talipes  varus  which  are  permanent.  The  so-called 
"varus  position"  is  an  adventitious  curvature  occurring  temporarily  in 
certain  forms  of  arthritis  or  with  temporary  muscular  contraction,  but 
under  certain  circumstances  it  may  become  permanent. 

Etiology. — Of  the  two  main  types  of  talipes  varus,  congenital  and 
acquired,  the  former  comprises,  according  to  Bessel-Hagen,  74  per  cent., 
the  latter  only  26  per  cent,  of  all  cases.  Of  congenital  talipes  varus,  we 
distinguish  after  Bessel-Hagen  a  primary  or  idiopathic,  and  a  secondary 
variety.  The  former  is  due  to  faulty  construction  of  the  embryonal 
trace  or  arrested  development;  the  latter  to  the  action  of  mechanical 
forces  upon  the  normal  foot  in  utero.  Study  has  shown  that  primary 
talipes  varus  is  rare.  Although  the  primary  and  secondary  forms  are 
not  sharply  divided,  the  distinction  is  useful  in  discussing  the  patho- 
genesis. 

Among  the  primary  forms  belong  those  with  defect  of  an  important 
bone;  most  frequently  the  tibia.  Absence  of  one  or  more  tarsals, 
sometimes  with  deficiency  of  the  toes,  syndactylia,  and  anomalies  of 
the  muscles,  have  also  been  recorded.  Some  of  these  are  due  to  faulty 
construction  of  the  embryo,  others  to  arrested  development.  To 
arrested  development  Bessel-Hagen  also  attributes  the  anomalies  of  the 
muscles,  faulty  insertion  of  the  muscles  and  of  the  fundiform  ligament, 
and  the  cases  of  embryonal  talipes  varus  in  which  there  is  a  well- 
developed  joint  between  the  fibula  and  calcaneum. 

In  talipes  varus  due  to  arrested  development  there  are  elements 
resembling  those  found  in  the  lower  orders  of  the  phylogenetic  evolu- 
tionary series;  for  example,  the  oblique  direction  of  the  long  neck  of 
the  astragalus,  which  is  found  in  the  orang-outang,  and  to  which  atten- 


CONTRACTURES  AM>  DEFORMITIES  OF  THE  FOOT.         801 

tion  was  called  by  Parker  and  Sliattoek;  also  the  extended  position  of 
the  two  posterior  tarsals,  found  in  the  foot  of  digitigrade  mammalia. 
But  it  would  be  wrong  to  attribute  such  apparent  similarities,  which 
are  also  found  in  secondary  talipes  varus,  to  atavism.  Many  of  the 
peculiarities  of  the  talipes  varus  type  of  arrested  development  point  to 
a  continuation  of  an  even  earlier  stage.  Bessel-Hagen's  conception  of 
these  relations  differs  entirely  from  the  earlier  generally  accepted  views. 

Dieffenbach  at  first  maintained  that  the  newly  born  always  came  into 
the  world  with  talipes  varus  of  the  first  degree.  Esehrieht  tried  to  show 
that  the  foot  was  even  more  strongly  inverted  earlier  in  foetal  life  than 
in  the  newborn.  The  lower  extremities  were  supposed  to  be  rotated  in 
the  beginning  so  that  their  posterior  surfaces  lay  against  the  abdomen 
with  the  little  toes  side  by  side.  Then,  as  the  extremities  grew,  they 
became  twisted  in  the  long  axis  and  in  a  spiral  direction.  If  the  lower 
end  of  the  extremity  escaped  in  this  torsion  process,  the  foot  grew  in  this 
anomalous  position  and  became  a  talipes  varus.  This  theory,  once 
defended  by  Volkmann,  has  been  recently  brought  forward  again,  slightly 
modified,  by  Berg. 

Hiiter  proceeded  on  Dieffenbach's  assumption  that  normally  the  foot 
of  the  newborn  was  inverted.  He  tried  to  prove  this  by  the  differences 
which  he  and  Adams  found  in  the  normal  foot  of  the  foetus,  newborn, 
and  adult.  By  comparing  talipes  varus  with  the  normal  foot  of  the 
newborn  he  was  led  to  assume  that  talipes  varus  was  a  pathological 
exaggeration,  as  it  were,  of  the  physiological  inversion  position,  due  to 
excessive  development  of  the  bones  and  joints  of  the  foetus  in  certain 
directions  corresponding  to  this  inversion  position. 

Bessel-Hagen's  investigations,  the  results  of  which  agreed  with  those 
of  Scudder,  showed  that  this  theory  was  based  on  false  premises.  Bessel- 
Hagen  affirms  that  the  torsion  of  the  extremity  does  occur,  but  not  uni- 
formly or  to  the  same  extent  always,  and  that  it  does  not  influence  the 
position  of  the  foot  with  reference  to  the  limb;  also  that  in  talipes  varus 
the  limb  is  almost  always  rotated  inward;  while,  according  to  this  theory, 
it  ought  to  be  twisted  outward,  as  in  sympus  a  pus.  From  his  investiga- 
tions concerning  the  relation  of  the  foot  to  the  limb  during  embryonal 
life  he  agrees  entirely  "that  the  embryonal  foot  is  normally  markedly 
extended,  but  that  it  gradually  becomes  more  flexed  without  the  develop- 
ment meanwhile  of  any  pronounced  so-called  physiological  varus  position. 
To  be  sure,  there  is  as  a  rule  a  very  slight  deviation  in  the  sense  of 
adduction,  but  simultaneous  inversion  is  extremely  rare." 

The  results  of  these  investigations  are  confirmed  by  other  authors,  so 
that  Esehrieht  and  Berg's  torsion  theory  seems  to  be  disposed  of.  Also 
Hiiter's  theory,  as  there  is  therefore  no  stage  of  development  in  which 
the  inversion  or  varus  position  would  be  a  physiological  one.  The  ana- 
tomical similarity  which,  according  to  Hiiter,  exists  between  the  bones 
in  talipes  varus  and  in  the  newborn,  can  in  fact  be  referred  to  a  large 
extent  to  individual  variations,  and  are  therefore  unimportant.  In 
fact  the  anomalies  in  talipes  varus  are  not  always  in  the  direction  of 
exaggeration  of  normal  foetal  forms,  but  often  just  the  opposite.  For 
Vol.  III.— 51 


802 


DISEASES  OF  THE  ASKLE  AXD  FOOT. 


example,  the  posterior  portion  of  the  calcaneum  deviates  inward  from 
the  long  axis  of  the  astragalus  more  in  the  normal  foetus  than  in  the 
adult,  while  in  congenital  talipes  varus  it  deviates  outward. 

According  to  Bessel-Hagen's  theory  only  the  extended  position  of  the 
two  posterior  tarsals  in  primary  talipes  varus  due  to  arrested  develop- 
ment can  be  explained  by  a  reversion  to  an  earlier  stage  of  development. 
He  explains  the  rare  congenital  talipes  equinus  in  this  way.  The  rarity 
of  these  forms  is  easily  explained  by  the  fact  that  in  the  extended  position 


Fig.  500. 


\ 


< 


.„..?' 


Fig.  .501. 


Vfcs$ 


Position  of  the  feet  in  utero.     (Banga.) 

the  foot  is  subjected  to  a  greater  extent  to  the  action  of  external  me- 
chanical forces  (uterine  pressure,  etc.),  which  obviously  tend  most  fre- 
quently to  invert  the  foot.  Bessel-Hagen  does  not  deny  the  influence  of 
pressure  in  primary  talipes  varus,  but  still  regards  the  inherent  peculi- 
arities of  the  foot  as  the  dominant  factor  in  its  production.  As  stated, 
these  peculiarities  are  supposedly  the  flattening  of  the  corpus  tali  and 
anteroposterior  convergence  of  its  sides,  the  deviations  of  the  insertions 
of  ligaments  and  tendons,  and  the  existence  of  a  calcaneofibular  joint. 
The  author  cannot  regard  these  changes  as  characteristic  of    arrested 


L'OSTRAVTUllES  A  XI)  DEFORMITIES  OF  THE  FOOT. 


803 


developm*  nt  nor  attribute  all  these  deviations  and  displacements  to  the 
period  in  which  the  muscles,  tendons,  ligaments,  and  joints  are  being 
formed.  He  believes  instead  that  capsule  insertions  and  tendons  can 
become  shifted  and  abnormal  joints  be  formed  later  in  intrauterine  life 
under  the  influence  of  mechanical  forces  which  produce  faulty  positions. 
The  author  further  believes  that  the  only  safe  conclusion  which  can  be 
drawn  from  such  displacement  is,  that  talipes  varus  develops  at  a  rela- 
tively early  stage,  and  that  it  is  still  impossible  to  determine  whether  it 
is  caused  by  arrested  development  of  the  joints,  ligaments,  and  tendon 
insertions,  or  secondary  changes  due  to  mechanical  forces. 

The  occurrence  of  primary  idiopathic  talipes  varus  is  verified  by  the 
fact  that  this  and  other  primary  deformities  are  inherited.     The  occur- 


I'h..  502. 


Fig.  503. 


Interlocking  of  the  feet.     (Volkmann  and  Vogt.) 

rence  of  congenital  talipes  varus  in  several  children  of  the  same  family 
does  not  exclude  the  agency  of  external  mechanical  causes;  but  such 
causes  cannot  be  assumed  in  the  cases  in  which  talipes  varus  is  inherited 
from  the  father  or  mother  or  repeated  through  three  generations,  or 
transmitted  from  the  first  to  the  third  generation. 

The  secondary  cases  are  more  numerous;  their  production  in  utero 
by  external  forces  was  taught  by  Hippocrates  and  Galen.  Only  recently 
has  the  influence  of  abnormal  pressure  been  studied  and  verified. 
Sometimes  the  attitude  of  the  fcetus  in  utero  can  be  determined  from  the 
position  of  the  feet  and  limbs  and  the  deformity  of  the  feet.  (Figs.  500 
and  501.)  One  or  both  feet  may  be  in  the  varus  position,  or  one  varus 
and  the  other  a  talipes  calcaneus  or  calcaneovalgus ;  in  the  latter  case 
the  feet  are  often  interlocked.     (Figs.  502  and  503.)     The  pressure- 


804  DISEASES  OF  THE  ANKLE  AND  FOOT. 

marks  on  the  skin,  first  described  by  v.  Volkmann,  are  even  more  positive 
evidence  of  mechanical  influence.  These  spots  are  small,  glossy, 
almost  round,  the  skin  atrophic  and  covered  with  only  a  thin  layer  of 
epidermis;  the  papillae,  sweat  and  sebaceous  glands  are  absent,  and  a 
small  bursa  may  replace  the  subcutaneous  fat;  the  marks  are  found  on 
the  prominences — e.  g.,  external  malleolus — which  are  exposed  to  the 
pressure  of  the  uterus  or  the  fcetal  body.  The  pressure  necessary  to 
produce  talipes  varus  must  naturally  be  greater  than  the  physiological 
energy  of  growth  of  the  foetus;  it  is  not  so  great,  however,  as  that  required 
to  limit  movements  of  the  foetus  and  check  the  full  development  of  the 
muscles.  Nor  does  it  have  to  be  continuous.  It  suffices  that  the  foot 
is  held  inverted  in  the  intervals  of  rest.  The  abnormal  conditions 
essential  to  the  production  of  talipes  varus  are  attributable  to  the  uterus 
and  to  the  foetus.  In  the  former  case  they  are  adhesions  between  the 
amnion  and  foetus,  rarely  from  the  foetus  becoming  entangled  in  the 
umbilical  cord,  and  most  frequently  insufficient  space.  The  latter  is 
probably  due  less  to  lack  of  distensibility  on  the  part  of  the  uterus  than 
to  a  relatively  insufficient  secretion  of  liquor  amnii.  This  lack  of  room 
also  explains  the  coexistent  contractures  sometimes  seen  in  other  joints, 
for  example,  club-hands.  The  effect  is  increased  if  the  position  of  the 
limbs  is  faulty;  this  explains,  for  example,  the  coexistence  of  congenital 
contractures  or  dislocations  of  the  hip-  and  knee-joints  and  talipes 
varus.  Tumors  of  the  uterus,  numerous  pregnancies,  bilateral  deformi- 
ties, and  twins  can  also  decrease  the  intrauterine  space.  K.  Roser 
assumes  that  the  foot  is  twisted  by  striking  the  uterus  obliquely  during 
its  movements.  This  is  true  for  some  cases.  The  conditions  attrib- 
uted to  the  foetus  are,  improper  position  of  the  limbs,  faulty  construction 
of  the  primitive  trace,  contractures  and  dislocations  of  the  knee  and  hip, 
foetal  rhachitis  (rare),  diseases  and  defects  of  the  central  nervous  system 
with  congenital  paralyses  (hydrocephalus,  rhachischisis  and  spina 
bifida,  encephalocele  and  anencephalus).  The  fact  that  talipes  varus 
occurred  in  connection  with  these  forms  of  paralysis  was  turned  to 
account  in  defence  of  the  theory  that  talipes  varus  in  general  was  due  to 
muscular  and  nervous  disturbances,  a  theory  relinquished  some  time 
ago.  That  the  talipes  varus  associated  with  congenital  paralysis  is  not 
due  directly  to  the  results  of  the  paralysis,  but  to  mechanical  forces,  is 
attested  to  by  the  pressure-marks  seen  in  these  cases  and  the  fact  that 
the  feet  are  reciprocally  deformed,  for  example,  the  coexistence  of 
talipes  varus  of  one  foot  with  valgus  of  the  other,  or  of  genu  valgum 
with  genu  varum ;  also  the  occasional  existence  of  only  one  talipes  varus 
in  complete  paralysis  of  both  limbs. 

The  acquired  form  may  develop  immediately  after  trauma,  fractures 
of  the  malleoli  or  the  tarsals,  dislocations  in  the  tibiotarsal  or  medio- 
tarsal  joint,  or  dislocation  of  the  astragalus  alone.  The  deformity  is 
naturally  increased  if  the  foot  is  used  in  the  abnormal  position,  and  may 
become  very  marked  and  permanent. 

Much  more  frequent  than  the  above  immediate  or  primary  forms  of 
acquired  club-foot  are  the  secondary  forms,  which  do  not  follow  imme- 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.         805 

diately  after  the  causal  disease  or  condition,  1  > 1 1 1  are  produced  by  the 
action  <>f  deforming  forces  whose  activity  first  comes  into  play  as  a 
result  of  the  causal  condition. 

Part  of  these  cases  may  be  termed  static  talipes  varus.  If  the  leg  is 
held  strongly  abducted,  as,  for  example,  in  genu  valgum,  the  sole  of  the 
foot  cannot  be  planted  squarely  on  the  ground  unless  the  foot  is  inverted. 
If  the  altered  line  of  pressure  thus  established  is  continued,  the  temporary 
abnormal  position  may  become  fixed  and  permanent,  although  rarely 
reaching  a  high  grade.  It  may  develop  similarly  if  the  lower  third  of 
the  leg  is  curved  sharply  outward,  or  the  outer  border  of  the  foot  is  lower 
than  the  inner,  or  the  foot  is  inverted,  as,  for  example,  in  fractures  of  the 
leg  uniting  with  deformity  or  less  frequently  in  rhachitis  with  curvature 
of  the  leg.  Also  if  the  tibia  and  fibula  are  of  unequal  length,  as,  for 
example,  after  partial  resection  or  necrotomy,  or  with  excessive  long- 
growth  of  the  tibia  or  deficient  growth  of  the  fibula,  seen  most  frequently 
after  acute  osteomyelitis.  Further  it  may  be  due  to  ankylosis  following 
inflammations  of  the  joints  or  cicatricial  contraction  in  the  calf  or  sole  of 
the  foot. 

Other  forms  have  been  classified  as  "myogenic."  In  these  the 
position  of  the  foot  is  due  to  contraction  of  the  muscles  (contracture  by 
habit),  for  example,  to  prevent  pressure  upon  a  painful  affection  in  the 
sole  of  the  foot  or  tension  upon  painful  spots  of  inflammation  near  the 
ankle-joint  or  in  the  calf,  or  to  compensate  shortening  of  the  limb.  The 
foot  is  chiefly  in  the  equinus  position  in  these  cases.  Among  the  habitual 
contractures  may  be  classified  the  cases  of  talipes  varus  due  to  long  im- 
mobilization of  the  foot  in  a  faulty  position  or  to  protracted  recumbence. 
The  talipes  varus  due  to  a  primary  myopathy — e.  g.,  injuries  of  the  mus- 
cles of  the  calf,  myositis  fibrosa,  syphilitic  induration  of  the  calf  muscles 
and  ischemic  paralysis  of  the  muscles — is  the  result  of  cicatricial  con- 
traction. The  deformities  which  follow  division  of  the  dorsal  flexors  or 
occur  in  connection  with  pseudohypertrophy  of  the  muscles  are  more 
closely  allied  to  the  large  group  of  talipes  due  to  neurotrophic  disturb- 
ances of  the  muscles  of  the  leg. 

Under  neuropathic  talipes  varus  are  classified  the  intermittent  spastic 
contractures,  which  may  gradually  become  permanent  deformities. 
They  are  found  most  frequently  with  cerebral  and  spinal  paralysis,  dis- 
eases of  the  spine  and  brain  accompanied  by  muscular  spasm  and 
increased  reflex  irritability,  in  hysteria,  and  in  certain  poisonings,  such 
as  lead- poisoning  and  ergotism.  Spastic  talipes  varus  is  rare  compared 
to  the  paralytic  form. 

Paralytic  talipes  varus  is  the  most  frequent  of  all  the  acquired  forms. 
The  foot  is  extended,  inverted,  and  adducted  by  its  own  weight,  and  is 
then  fixed  in  this  position  by  the  shrinkage  of  the  muscles,  tendons,  liga- 
ments, and  capsules.  The  effect  of  gravity  upon  the  foot  is  shown  in  v. 
Volkmann's  cases  in  which  the  calf  muscles  were  paralyzed;  the  peronei 
and  dorsal  flexors  still  reacted,  although  weakly;  nevertheless  a  talipes 
equinovarus  developed,  because  the  growth  of  the  leg  was  retarded,  and 
the  child,  therefore,  had  to  let  the  foot  drop  in  order  to  touch  the  ground 


806 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


with  the  toes.  The  talipes  varus  was  accordingly  not  only  paralytic,  but 
also  compensatory.  It  was  stated  above  that  if  only  the  dorsal  flexors 
and  evertors  were  paralyzed  and  the  action  of  the  sound  muscles  and 
of  gravity  was  therefore  in  the  same  direction,  the  varus  position  devel- 
oped and  became  fixed  more  rapidly  and  reached  a  higher  grade.  The 
fact  that  the  paralysis  is  not  infrequently  limited  to  the  dorsal  flexors 
or  evertors,  together  with  the  great  influence  of  gravity,  is  responsible 
for  talipes  equinovarus  being  by  far  the  most  frequent  form  of  paralytic 
contractures  of  the  foot. 

It  was  also  stated  above  that  the  varus  position  could  be  prevented 
by  the  everting  action  of  bearing  the  weight  on  the  foot  when  planted 
flatly.  This  seldom  happens,  however,  because  in  walking  the  limp 
foot  is  very  apt  to  strike  the  ground  with  its  outer  border,  and  because 
in  most  of  the  cases  an  equinovarus  contracture  already  exists  before 
the  patient  begins  to  walk.  Both  of  these  factors  are  naturally  active 
to  an  even  greater  degree  in  the  cases  of  paralysis  limited  to  the  dorsal 

Fig.  .504. 


Skeleton  of  talipes  varus.     (Ch.  Nelaton.) 


flexors  and  evertors.  Furthermore,  every  attempt  to  walk  causes  the 
foot  to  be  drawn  into  the  contracture  position  by  the  active  contraction 
of  the  muscles.  Hence,  in  cases  of  partial  paralysis  use  of  the  foot  is 
almost  never  effectually  corrective,  so  that  contracture  is  the  constant 
result.  The  varus  contracture  once  established  is  increased  rapidly 
bv  weighting  the  foot. 

The  causes  of  paralysis  producing  paralytic  talipes  varus  are  so 
extremely  numerous  that  they  cannot  Vie  mentioned  here;  they  may 
be  peripheral,  but  are  much  more  often  of  central  nervous  origin. 
Acute  infantile  anterior  poliomyelitis  is  by  far  the  most  frequent  cause. 

From  the  above  it  follows  that  talipes  varus  can  develop  at  almost 
any  period  from  the  formation  of  the  primitive  trace  to  advanced  age, 
and  from  the  most  diverse  causes.  Any  theory  attempting  to  refer 
all  the  various  forms  of  talipes  varus  to  a  common  cause,  therefore, 
seems  impossible.  Accordingly,  the  author  cannot  entirely  approve  of 
J.   Wolff's  effort  to  find  among  all  the  manifold  causes,  the  remote 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        807 
causes,  « » t"  talipes  varus,  a  common  etiological   factor,  an   immediate 

cause,   which   is  supposed    to  consist   of  an    inward    rotation   of  the  foot 
or  entire  limb,  and  a  hindrance  to  outward  rotation. 

Pathological  Anatomy. — The  most  important  changes  occur  in  the 
skeleton,  namely,  in  the  shape  and  relation  of  the  hones  and  in  their 
joints.  (Fig.  504.)  The  changes  are  so  manifold,  according  to  the 
etiology,  in  the  varieties  and  subvarieties  of  talipes  varus,  that  only  those 
in  the  congenital  form  will  he  described  and  the  several  deviations  from 
these,  occurring  in  the  acquired  forms,  merely  mentioned.  The  anat- 
omy of  primary  idiopathic  talipes  varus  has  been  little  studied;  there 
is  no  conclusive  evidence  thus  far  that  it  differs  from  that  of  the  second- 
ary form,  the  few  points  of  difference  given  by  Bessel-Hagen  being 
found  in  only  a  limited  number  of  cases.  It  is  also  questionable  whether 
these  points  are  confined  to  primary  talipes  varus. 

Fig.  505. 


A 


Astragalus  in  newborn  and  in  congenital  talipes  varus.     (William  Adams.) 

A,  1,2,  3.     Normal  astragalus  seen  from  above  and  from  under  and  outer  side. 

B,  1,2,  3.     Astragalus  in  newborn,  with  congenital  talipes  equinovarus,  seen  from  same  points. 

In  a  pronounced  case  of  talipes  varus  the  forepart  of  the  foot  is 
markedly  adducted  and  inverted;  the  tip  of  the  foot  is  extended  and 
points  inward;  the  sole  faces  inward;  when  placed  upon  the  ground 
the  foot  rests  upon  its  outer  border  or  even  upon  the  dorsum.  As  the 
most  important  changes  take  place  in  the  tarsal  joints  we  find  the 
astragalus  and  calcaneum  most  altered. 

The  astragalus  is  flattened  and  converges  more  than  usual  backward. 
(Fig.  505.)  The  trochlea  articulates  writh  the  tibia  only  by  its  posterior 
portion;  in  front  the  cartilage  is  atrophied.  Kocher  found  the  normal 
extension  angle  of  130  degrees  between  the  tibia  and  astragalus  increased 
to  150  degrees.  The  neck  is  lengthened  on  the  outer  side  and  twisted 
inward  (Adams,  Hiiter)  (Fig.  506),  forming  an  angle  with  the  sagittal 
axis  of  the  body  of  the  bone  of  50  to  64  degrees,  instead  of  the  normal 
11  degrees  in  adults  and  38  degrees  in  the  newborn.  (Parker,  Shattock.) 
To  this  is  due  the  inflexion  of  the  foot  in  Chopart's  joint.  The  scaphoid 
and  cuboid  are  subluxated  inw^ard.     The  anterior  process  of  the  calca- 


808 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


neum  is  thicker  vertically  (Hiiter);    this  prevents  full  eversion  of  the 
foot.     The  sustentaculum  is  depressed  or  absent. 

The  calcaneum  is  extended  more  than  the  astragalus;  it  is  also 
adducted;  its  posterior  portion  may  articulate  with  the  tibia  and  fibula. 
Normally  the  long  axis  of  the  calcaneum  forms  an  angle  opening  forward 
with  the  astragalus;  in  congenital  talipes  varus  the  long  axis,  aside 
from  its  oblique  direction  downward,  runs  forward  and  inward. 
(Figs.  507  to  509.)  The  tuberosity  is  thus  shifted  outward  toward  the 
external  malleolus,  and  the  anterior  process  is  turned  inward.     The 


Fig.  506. 


f 


9 


Obliquity  of  the  neck  of  the  astragalus,  a.  Normal  astragalus  in  adult.  A  sagittal  line  through 
the  middle  of  the  trochlea  forms  an  angle  of  12  degrees  with  a  line  along  the  outer  border  of 
the  neck.  This  angle,  b,  in  a  normal  full-grown  foetus  =  35  degrees;  c,  in  a  full-grown  chim- 
panzee, =  27  degrees;  d,  in  a  young  full-grown  orang-outang,  =  45  degrees;  e,  in  a  child  of 
eighteen  months,  with  talipes  varus,  =  56  degrees;  /,  in  a  seven  months'  fcetus,  with  talipes  varus, 
=  64  degrees;  g,  in  a  four  to  five  months'  fcetus,  with  talipes  varus,  =  44  degrees;  ft,  in  a  seven 
months'  fcetus,  in  which  the  angle  is  strikingly  small,  =  31  degrees.     (Parker  and  Shattock.) 


calcaneum,  as  a  whole,  is  displaced  outward,  somewhat,  so  that  the 
calcaneofibular  ligament  (middle  fasciculus  of  external  lateral  ligament) 
is  greatly  shortened  and  the  external  malleolus  is  retarded  in  growth. 
The  long  axis  of  the  calcaneum  may  be  curved  so  that  the  bone  is 
convex  outward.  (Kocher.)  From  this  curvature  and  the  rotation  of 
the  axis  described  by  Bessel-Hagen  it  can  be  understood  how  the 
articulation  for  the  cuboid  becomes  shifted  entirely  to  the  inner 
surface. 

The    calcaneo-astragaloid    joint    is    correspondingly    altered.      The 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 


809 


surface  on  the  calcaneum  is  directed  more  inward,  the  long  diameter 

downward  and  inward;  it  is  also  convex  from  before  backward,  and 
divided  by  slight  crista'  into  three  parts.  The  highest  and  most  external 
of  the  surfaces  corresponds  to  the  articulation  for  the  external  malleolus 
and  the  tibia,  the  middle  surface,  which  goes  to  form  the  convexity 
largely,  corresponds  in  its  anterior  portion  to  the  articulation  for  the 
astragalus,  and  in  its  posterior  to  that  for  the  tibia;  the  inner  surface, 
which  represents  the  completely  atrophied  apophysis  of  the  calcaneum, 
corresponds  to  the  lower  and  inner  portions  of  the  facets  of  the 
astragalus.  These  conditions  are  pronounced  in  direct  relation  to  the 
age  of  the  case.  The  changes  in  the  smaller  tarsals  and  metatarsals 
are  unimportant. 


Fig.  507. 


Fig.  508. 


Fig.  509. 


Smi 


I  \c 

Fig.  507. — Normal  foot. 

Fig.  508. — Idiopathic  congenital  talipes  varus  in  newborn. 

Fig.  509. — Same  in  adult,  a  b.  Long  axis  of  body  of  astragalus.  C  d.  Long  axis  of  os  calcis.  TV. 
Trochlea  of  astragalus.  *'.  m.  i.  Surface  for  internal  malleolus.  S.  m.  e.  Surface  for  external 
malleolus.  P.  a.  c.  Anterior  process  of  os  calcis.  6'.  t.  Sustentaculum  tali.  S.  a.  n.  Articular 
surface  of  astragalus  for  scaphoid.  S.  a.  tf.  New  articulation  of  os  calcis  with  tibia  and  fibula. 
C.  t.  Head  of  the  astragalus. 


The  tibia  and  fibula  may  be  rotated  inward  in  their  lower  portion 
about  the  long  axis  of  the  leg  so  that  the  external  malleolus  faces  forward 
and  outward  instead  of  outward  and  backward.  (Eschricht,  Adams, 
v.  Volkmann,  Kocher,  and  others.)  The  transverse  axis  of  the  foot  thus 
runs  from  behind  and  the  inner  side  forward  and  outward.  As  a  rule, 
the  fibula  is  underdeveloped  and  curved  toward  the  tibia,  so  that  the 
interosseous  space  is  narrowed.  There  are  instances  in  which  the 
tibia  and  fibula  were  rotated  outward.  In  talipes  varus  due  to  uterine 
pressure  they  may  be  curved,  convex  outward. 

Usually  the  subluxations  are  more  pronounced  than  deformation 
of  the  bones;  at  the  same  time  the  insertions  of  the  ligaments  become 
shifted  gradually,  the  joint-capsules  shrink,  and  the  periosteum  pro- 
liferates at  the  points  of  insertion.     The  greatest  amount  of  displace- 


810  DISEASES  OF  THE  AX  RLE  A  XL)  FOOT. 

ment  occurs  in  the  mediotarsal,  tibiotarsal,  and  calcaneo-astragaloid 
joints.  The  astragalus  is  forced  forward  by  excessive  extension  and 
inversion  from  between  the  malleoli  and  becomes  adducted,  so  that 
during  flexion  of  the  foot  the  front  of  the  tibia  strikes  against  the 
trochlea  and  may  form  a  groove  in  it.  The  malleoli  become  approxi- 
mated and  together  with  the  growth  of  periosteum  on  the  front  of  the 
astragalus  prevent  reduction.  The  calcaneum  becomes  inverted,  so 
that  the  tuberosity  is  separated  farther  from  the  tip  of  the  external 
malleolus,  in  contrast  to  its  approaching  it  in  the  congenital  form.  In 
contrast  also  to  the  congenital  form  the  bones  of  the  leg  are  usually 
rotated  outward. 

The  soft  parts  as  a  whole  are  shortened  on  the  concave  side  and 
lengthened  on  the  convex  side  of  the  foot.  Shrinkage  also  takes  place 
in  the  calf.  The  ligaments  are  shortened  most  in  the  region  between 
the  internal  malleolus,  calcaneum,  astragalus,  scaphoid,  and  first  cunei- 
form. The  capsule  of  the  ankle-joint  is  shrunken  behind,  and  in  front 
it  is  either  stretched  by  the  extended  position  of  the  anterior  border 
of  the  trochlea  of  the  astragalus,  or  is  inserted  on  the  astragalus  close 
to  the  anterior  margin  of  the  tibia,  and  thus  stretched  tightly  across 
the  cleft  of  the  joint.  In  the  latter  case  the  insertion  is  displaced,  a 
condition  which  Bessel-Hagen  regarded  as  characteristic  of  the  primary 
talipes  varus. 

Of  the  muscular  shortening,  that  of  the  gastrocnemii  is  most  im- 
portant; the  tibialis  anticus  and  posticus  and  short  plantars  are  also 
shortened.  Of  the  shortening  of  the  soft  parts  in  the  sole,  that  of  the 
skin  and  plantar  fascia  has  the  greatest  significance. 

The  tendons  in  the  foot  are  often  shifted  in  proportion  to  the  degree 
of  the  deformity.  The  groove  for  the  peronei  is  shifted  to  the  outer 
and  under  surface  of  the  anterior  process  of  the  calcaneum  instead  of 
being  on  the  under  surface  of  the  cuboid.  The  tendon  of  the  tibialis 
posticus  runs  along  a  smooth  groove  on  the  posterior  surface  of  the 
tibia  to  the  posterior  margin  of  the  internal  malleolus.  The  dorsal 
flexors  are  mostly  displaced  inward  and  with  them  the  fundiform 
ligament  is  drawn  inward  and  lengthened.  In  some  instances  the 
ligament  is  inserted  on  the  outer  or  dorsal  side  of  the  neck  of  the  astrag- 
alus or  on  the  same  side  of  the  scaphoid,  instead  of  in  the  sinus  tarsi. 
Bessel-Hagen  regards  this  anomalous  insertion  as  peculiar  to  idiopathic 
talipes  varus;  in  these  cases  he  also  found  the  origins  of  the  short  foot 
muscles  shifted  and  abnormal  ligaments  at  the  joints.  In  other  respects 
the  muscles  are  unchanged,  as  a  rule,  in  congenital  non-paralytic  talipes 
varus.  Very  rarely  one  finds  a  slight  amount  of  intrauterine  atrophy, 
which  is  referable  to  lack  of  movement  of  the  foetal  foot. 

As  long  as  the  foot  is  not  used  to  stand  or  walk  no  essential  changes 
occur,  but  the  first  attempts  to  walk  increase  the  deformity  if  the  foot 
is  inverted  farther,  and  not  everted,  by  the  body-weight.  The  more 
the  dorsum  becomes  the  supporting  point  of  the  foot,  the  greater  becomes 
the  extension  and  inversion  and  the  inflexion  in  (  nopart's  joint.  This 
leads  to  subluxations,  to  further  deformation,  and   the  formation  of 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.         811 

new  joints.  The  astragalus  may  be  dislocated  from  between  the  malleoli. 
The  posterior  part  of  the  trochlea,  still  in  contact  with  the  malleoli, 
may  be  reduced  in  length  to  a  few  millimetres,  become  flattened  and 
atrophic,  while  the  anterior  part,  carried  with  disintegrating  cartilage, 
becomes  irregularly  thickened,  and  thus  may  prevent  reduction.  The 
capsule  may  become  adherent  to  the  cartilaginous  surface  in  front. 
Knpprecht  has  called  attention  to  the  changes  in  the  body  of  the  astrag- 
alus; in  talipes  varus  it  represents  a  wedge  driven  in  between  the  arch 
of  the  foot  and  the  leg  from  in  front  and  the  outer  side.  The  frontal 
section  is  no  longer  a  quadrate,  as  in  a  normal  foot,  but  a  trapezoid, 
in  very  pronounced  cases  a  triangle  with  apex  at  the  inner  side.  The 
neck  becomes  more  and  more  curved  downward  and  inward,  the 
scaphoid  becomes  increasingly  subluxated  and  the  articular  surface 
of  the  caput  tali  more  distinctly  divided  into  two  parts.  The  calcanenm 
is  increasingly  extended  and  inverted;  often  the  upper  surface  comes 
to  articulate  with  the  posterior  edge  of  the  tibia  and  fibula.  The  tuber- 
osity remains  in  close  proximity  to  the  external  malleolus.  The  calca- 
neum  appears  longer  and  lower,  although  the  anterior  process  is  rela- 
tively high.  The  cuboid  gradually  becomes  subluxated  inward.  The 
abnormal  relation  of  the  other  bones  and  joints  of  the  tarsus  and  meta- 
tarsus becomes  more  marked,  and  in  consequence  the  arching  and 
inflexion  of  the  sole  at  the  inner  border  more  pronounced,  eventually 
even  to  an  acute  angle. 

The  muscles  of  the  foot  and  leg,  in  fact  to  a  certain  extent  of  the 
entire  extremity,  atrophy,  but,  as  a  rule,  without  apparent  changes  in 
the  nerves.  Even  after  correction  the  atrophy  of  the  calf-muscles 
persists,  a  fact  explained  by  the  changed  function  of  the  gastrocnemii, 
which  does  not  return  to  normal  after  correction. 

The  changes  in  the  bones  extend  throughout  the  entire  extremity 
and  to  the  pelvis  and  spinal  column,  as  shown  especially  by  H.  v. 
Meyer.  The  line  of  gravity  of  the  body  is  thrown  far  back  in  talipes 
varus  because  of  the  lack  of  support  normally  given  by  the  metatarsals; 
the  patient  walks,  therefore,  with  the  body  curved  backward.  This 
curvature  is  increased  by  inclination  of  the  pelvis  and  consequent 
lordosis.  The  gait  is  inelastic.  The  lateral  equilibrium  is  facilitated 
by  rotating  the  legs  inward;  as  the  result  the  posterior  and  outer  part 
of  the  articular  surface  of  the  head  of  the  femur  degenerates,  the  pelvis 
becomes  more  inclined  and,  as  the  pressure  of  the  femur  acts  more  in 
the  direction  of  the  sacrum,  it  gradually  becomes  narrowed  laterally. 
This  sequence  given  by  v.  Meyer  does  not  always  take  place,  as  one 
occasionally  finds  the  leg  rotated  abnormally  outward. 

In  acquired  talipes  varus  the  pathologico-anatomical  changes  vary 
at  the  outset,  obviously,  according  to  the  etiology.  These  differences 
become  somewhat  less  marked  after  the  foot  has  been  used  for  any 
length  of  time,  so  that  the  changes  may  resemble  those  in  old  cases 
of  congenital  origin.  As  a  rule,  at  the  outset  the  foot  is  merely  fixed 
in  the  positions  possible  physiologically,  but  gradually  these  positions 
are  exaggerated  and  are  followed  by  subluxations  and  changes  in  the 


812  DISEASES  OF  THE  ANKLE  AND  FOOT. 

bones.  The  latter  develop  chiefly  in  the  cases  occurring  in  childhood, 
less  rapidly  in  those  acquired  later  in  life.  The  astragalus,  for  example, 
may  undergo  deformation  similar  to  that  in  congenital  talipes  varus, 
but  usually  the  deviation  of  the  neck  is  not  so  marked.  For  this  reason 
the  inflexion  in  the  line  of  (  nopart's  joint,  which  occurs  so  frequently 
in  the  congenital  forms,  is  absent,  as  a  rule,  in  the  acquired  cases. 

Symptoms  and  Diagnosis. — The  clinical  picture  of  talipes  varus  may 
be  constructed  from  the  pathological  anatomy. 

In  the  congenital  form,  as  seen  in  children,  the  foot  is  inverted  and 
adducted,  in  severe  cases  till  at  an  acute  angle  to  the  leg.  The  sole  of 
the  foot  faces  inward  or  even  backward,  the  inner  border  upward,  the 
outer  downward.  The  foot  appears  shortened,  because  it  is  bent  upon 
itself.  This  inflexion  at  about  the  scaphoid  maybe  very  sharp.  The 
tip  of  the  foot  is  depressed,  the  heel  elevated  and  often  narrow  and  short, 
so  that  the  tuberosity  can  hardly  be  felt.  The  latter  lies  nearer  the 
external  malleolus,  which  in  turn  projects  prominently  and  often  lies 
farther  back  than  normally.  The  internal  malleolus  is  less  prominent 
than  normally.  The  dorsum  of  the  foot  is  unduly  arched  and  irregular, 
owing  to  the  projection  of  the  head  of  the  astragalus  and  the  anterior 
process  of  the  calcaneum. 

If  the  patient  walks,  the  deformity  is  increased  until  the  weight  is 
supported  on  the  outer  border  or  even  the  dorsum  of  the  foot.  The 
tuberosity  of  the  fifth  metatarsal,  or  the  cuboid  and  the  anterior  process 
of  the  calcaneum,  or  even  the  neck  and  trochlea  of  the  astragalus,  form 
the  point  of  support.  In  the  latter  case  the  dorsum  faces  forward  and 
downward,  and  the  sole  backward  and  upward.  A  deep  fold  divides 
the  anterior  from  the  posterior  portion  of  the  foot  at  the  level  of  the 
mediotarsal  joint.  The  foot  is  bent  together,  the  heel  small  and  atrophic. 
Thick  callosities  grow  on  the  dorsum  at  the  point  of  support,  and  under- 
neath the  skin  bursa?  develop  which  may  become  inflamed  and  painful, 
and  even  suppurate.  They  often  leave  fistulas.  The  muscles  of  the  leg 
atrophy,  so  that  the  leg  and  deformed  foot  look  like  a  stilt. 

The  appearance  of  acquired  talipes  varus  is  very  similar,  varying 
according  to  the  degree  of  the  curvature.  In  the  paralytic  form  the 
coolness  and  bluish  color  of  the  skin,  the  atrophy  of  the  muscles,  and  if 
acquired  in  childhood,  the  shortening  of  the  limb,  are  very  striking. 
The  plantar  flexion  of  the  foot  and  toes  is  more  marked  even  in  mild 
cases.  On  the  other  hand,  the  inflexion  at  the  mediotarsal  joint,  the 
changes  in  the  tarsus,  and  the  proximity  of  the  tuberosity  of  the  calca- 
neum to  the  external  malleolus  are  less  pronounced  than  in  the  con- 
genital form.  These  dissimilarities  and  the  history  make  the  differential 
diagnosis  of  the  paralytic  from  the  congenital  form  easy. 

Treatment. — The  treatment  of  congenital  talipes  varus  should  be 
instituted  soon  after  birth  if  the  child  is  healthy,  in  order  to  take  advan- 
tage of  the  rapid  growth  of  the  bones  during  the  first  few  months,  other- 
wise the  deformity  increases  proportionately.  The  shortness  of  the 
foot  often  makes  early  treatment  difficult;  nevertheless  it  is  preferable, 
especially  if  the  deformity  is  marked.     In  almost  all  cases  corrective 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 


813 


manipulation  and  massage  can  be  begun  immediately  after  birth.  The 
results  are  often  surprising.  As  the  manipulation  should  be  carried  out 
several  times  daily,  the  persons  caring  for  the  child  should  be  taught 
how  to  conduct  it.  Frequent  co-operation  is  advisable  on  the  part  of 
the  surgeon,  ;is  the  laity  do  not  usually  make  the  treatment  energetic 
enough.  The  lee  is  held  in  one  hand  while  the  foot  is  everted  and 
abducted  with  the  other;  or  if  the  inflexion  of  the  tarsus  is  marked,  the 
ankle  and  heel  are  held  in  one  hand  while  the  front  of  the  foot  is  flexed 
with  the  other.  If  the  foot  is  extended,  it  should  be  flexed  as  much  as 
possible.  This  order,  eversion  and  abduction,  and  then  flexion,  should 
be  followed  out  in  every  manipulation.  In  the  intervals  the  foot  can  be 
held  interruptedly  or  continuously  to  great  advantage  in  the  corrected 
position  by  means  of  a  bandage.  Adhesive-plaster  strips  hold  the  foot 
more  firmly,  but  are  not  so  easily  changed  and  are  apt  to  irritate  the  skin. 


Fig.  510. 


Fig.  511. 


Fig.  512. 


Konig's  felt-splint.     (Hoffa.) 


Various  splints  are  in  use.  Adams  fastens  a  straight  splint  along  the 
outer  side  of  the  leg,  so  that  it  extends  beyond  the  foot,  and  bandages 
the  latter  to  it.  Splints  made  of  pliable  felt  are  better.  (P.  Brims,  Vogt, 
Konig.)  A  form  is  cut  out  of  felt,  softened  by  heating,  and  bandaged 
to  the  corrected  foot  till  it  hardens;  it  is  then  taken  off  and  shaped;  the 
foot  is  bandaged  wTith  gauze  and  the  splint  then  bound  in  place.  (Figs. 
510,  511,  and  512.)  Any  material  which  is  pliable  and  hardens,  such  as 
rubber,  pliable  papier-mache,  or  tin,  etc. ,  may  be  used.  The  simple  appa- 
ratus of  Kolliker,  Taylor,  Beely,  and  others  act  similarly,  and  in  addition 
have  the  advantage  of  making  elastic  traction.  Beely's  splint  (Fig.  513) 
consists  of  three  curved  plates  padded  with  felt  and  connected  by  flexible 
iron  strips  adjustable  by  means  of  screws.  The  flexed  position  of  the 
knee  is  important  to  insure  continuous  eversion  and  flexion  of  the  foot. 
Kolliker's  splint  (Fig.  514),  an  iron  strip  with  a  thick  felt  pad,  is  made 
after  a  rubber  model  shaped  to  the  foot  and  leg  while  warm  and  pliable; 
it  runs  over  the  dorsum  of  the  foot,  under  the  sole  and  along  the  outer 
side  of  the  leg  to  above  the  knee.     These  splints  have  the  advantage  of 


814 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


being  removable  so  as  to  allow  manipulation,  baths,  massage,  etc.,  but 
have  the  disadvantage  of  being  hard  to  apply  accurately  and  of  pro- 
ducing decubitus;  hence  they  are  of  less  value  in  clinical  work  than 
permanent  splints. 

The  same  applies  even  more  to  the  numerous  club-foot  apparatus,1 
various  types  of  which  are  represented  by  the  apparatus  of  Scarpa 
(Fig.  515)  and  Meusel  (Fig.  516).  The  simplest  form  of  Scarpa's  splint 
consists  of  a  laced  shoe,  to  which  an  outer  strip  is  attached  on  the  sole. 
This  strip  is  hinged  at  the  level  of  the  ankle-joint  to  a  long  outer  strip 
fastened  below  the  knee  by  a  strap;  the  apparatus  makes  elastic  traction 
outward  on  the  foot,  and  thus  everts  it.  The  apparatus  of  Venel,  Stro- 
meyer,  Little,  Tamplin,  Adams,  Reeves,  Stillmann,  and  many  others 
are  constructed  very  much  on  the  same  principle.    Numerous  appliances 


Fig.  513. 


Fig.  514. 


Beely's  splint.     (Hoffa.) 


Kolliker's  splint.     (Hoffa.) 


were  constructed  to  overcome  the  adduction  of  the  foot,  for  example, 
by  means  of  spring  strips,  elastic  bands,  cog  wheels,  etc.,  fitted  to 
shoes,  the  front  part  of  which  could  be  rotated  outward.  The  same 
methods  were  used  to  overcome  the  extension.  Apparatus  were  also 
made  with  screw  appliances,  adjustable  ball  and  socket  and  hinge 
joints,  cog  wheels,  etc.,  and  used  partly  for  forcible  correction.  All 
of  these  apparatus  with  complicated  mechanism  are  little  used  at 
present. 

Elastic  traction  is  employed  more  frequently;  Barwell,  Sayre,  Andrews, 
Willard,  Prince,  and  Sprengel  have  suggested  simple  dressings  by  which 
it  can  be  applied.     Although  in  some  of  these  the  elastic  bands  are 


1  The  details  of  the  apparatus  and  the  bibliography  are  given  in  the  text-books  of  orthopaedic 
surgery  of  Schreiber,  Redard,  Hoffa,  and  others. 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 


815 


attached  to  the  foot  and  leg  by  means  of  adhesive  plaster,  they  are 
more  commonly  attached  to  a  shoe  with  side  strips  fastened  to  the 
leg.  (Hiiter,  Liicke,  Sayre,  Willard,  Stillmann,  Beely,  etc.)  Holla 
recommends  Hessing's  sheath  apparatus  with  elastic  bands.  Tin's 
makes  an  excellent  splint,  Imt  is  expensive.  Other  methods  of  fastening 
straps,  strips,  etc.,  to  the  foot  to  increase  the  lever  action  of  the  elastic 
traction  are  complicated  and  uncomfortable.  A  simple  method  of 
utilizing  the  action  of  body-weight  in  mild  cases,  or  for  after-treatment, 
is  to  drive  staples  (> — '  shaped)  into  the  outer  side  of  the  heel  and  of 
the  sole  at  the  ball  of  the  foot,  so  that  they  project  three-quarters  to  one 
inch  and  evert  the  foot  in  walking;  the  shoe  should  be  a  snugly  fitting, 
high-laced  boot  (Biigelschuh  of  Roser).  Older  patients  can  be  taught 
to  use  mechanical  apparatus  for  exercise  and  correction. 


Fig.  515. 


Fig.  516. 


Scarpa's  splint. 


Meusel's  apparatus  to  rotate  the  foot  outward. 


It  is  very  important  to  overcome  the  inward  rotation  at  the  knee-joint 
and  hip-joint.  It  often  persists  after  correction  of  the  club-foot  and 
increases  the  danger  of  recurrence,  whereas  outward  rotation  hinders 
adduction  of  the  foot.  Apparatus  may  be  necessary  to  prevent  inward 
rotation.  In  the  recumbent  patients  the  limb  is  easily  rotated  outward 
and  held  by  a  T-splint,  etc.  In  ambulant  patients  it  is  more  difficult; 
sometimes  an  iron  side  splint  fastened  to  a  pelvic  brace  is  sufficient; 
Charriere  shifted  the  attachment  farther  back  on  the  pelvic  brace; 
Liicke  and  Bruns  applied  an  apparatus  extending  down  to  the  knee 
and  rotated  it  outward  bv  means  of  an  elastic  band  running  backward 
from  the  outer  side  strip  to  the  pelvic  brace  or  a  belt;  Bonnet  controlled 


816  DISEASES  OF  THE  ANKLE  AND  FOOT. 

the  rotation  by  a  screw  at  the  pelvic  brace;  in  Meusel's  apparatus 
(Fig.  516)  the  leg  brace  is  rotated  and  fixed  on  the  lateral  thigh  strip 
at  the  knee;  in  Sayre's  brace  the  thigh  strip  is  rotated  by  means  of 
a  screw-key;  Beely's  scheme  of  an  elastic  band  fastened  to  the  outer 
thigh  strips  on  each  side  and  passing  across  the  pelvic  brace  behind 
is  simple  and  effectual;  Heusner  used  spiral  splints  made  of  flat  spring 
metal  and  of  three  grades  of  torsion  strength,  beginning  with  the 
weakest,  applying  it  only  at  night,  and  discontinuing  the  same  as  the 
resistance  diminished;  the  splints  were  fastened  to  the  shoe  by  a  catch. 
The  continuous  fixation  splints  are  unquestionably  the  simplest, 
require  the  least  supervision,  and  are,  therefore,  most  widely  used  in 
clinical  practice.  Of  these  the  permanent  plaster-splint,  formerly  used 
for  gradual  correction  of  the  deformity,  is  now  employed  chiefly  to 
maintain  the  position  after  manual  correction.  While  the  knee  is  held 
by  an  assistant,  the  foot  is  everted  and  flexed  as  far  as  possible  and 
held  in  this  position  by  hand  or  by  means  of  a  traction  bandage  around 

Fig.  517. 


- 


Oettingen's  method,     (v.  Bergmann.) 

the  mid-foot  pulled  upward  and  outward.  The  latter  makes  it  more 
difficult  to  apply  the  dressing  to  the  forefoot.  The  splint  should  be 
applied  with  little  or  no  padding,  extending  from  the  base  of  the  toes 
to  above  the  knee,  with  the  latter  flexed  slightly  to  insure  outward 
rotation  of  the  foot.  While  the  splint  is  soft  it  is  advisable  to  increase 
the  eversion  and  flexion  by  laying  the  hand  flat  against  the  sole  and 
pressing  upward  and  outward  until  the  plaster  hardens  or  by  placing 
the  foot  upon  the  ground  with  the  knee  flexed  and  pressing  the  leg 
directly  downward  and  outward.  Anaesthesia  facilitates  the  process 
greatly,  but  is  not  indispensable  unless  forcible  correction  is  necessary. 
Numerous  appliances  are  suggested  to  hold  the  foot  while  putting  on 
the  plaster,  but  are  superfluous. 

The  plaster  splint  is  left  on  for  from  three  to  six  weeks  unless  further 
correction  is  necessary,  in  which  case  it  is  removed  in  about  two  weeks 
and  renewed  after  increasing  the  eversion  and  flexion.  In  older  children 
it  is  better  to  have  them  use  the  foot;  to  strengthen  the  splint  for  this 
purpose  it  may  be  reinforced  with  starch  bandages,  or,  better,  with 
bandages  saturated  with  a  mixture  of  magnesium  carbonate  and  sodium 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.         817 

silicate  or  a  solution  of  celluloid  and  acetone.     This  makes  a  strong 
and  impervious  dressing. 

The  method  proposed  by  Oettingen,  and  in  use  for  some  time  in 
v.  Bergmann's  clinic,  is  simple  and  especially  useful  in  cases  of  talipes 
varus  in  the  newborn  and  young  children.  (Fig.  517.)  After  the  foot 
has  been  corrected  by  manipulation,  it  is  painted  with  Fink  and  Heus- 
ner's  adhesive  mixture  (terebinth,  venet.  15,  mastich  12,  resin  28, 
resin,  alb.  8,  alcohol  (90  per  cent.)  180,  ether  25).  A  twilled  bandage 
is  then  applied  beginning  at  the  outer  border  of  the  foot,  passing  over 
the  dorsum  to  the  inner  border  and  then  under  the  sole;  it  becomes 
firmly  adherent  in  a  few  seconds.  The  lower  third  of  the  thigh  is  then 
painted;  the  foot  is  then  abducted  and  everted,  and  the  bandage  drawn 
tightly  over  the  flexed  knee  and  passed  around  and  behind  the  calf, 
then  downward  over  the  front  of  the  foot  to  the  inner  side,  and  under- 
neath the  foot  to  the  outer  border.  Three  turns  may  be  made  in  this 
maimer.  The  first  dressing  is  left  on  two  days  and  the  later  ones  for 
two  or  three  weeks.  The  last  dressing  is  replaced  by  an  elastic  bandage, 
It  to  2  inches  wide,  with  buckles,  applied  in  the  same  manner  and 
worn  at  night.  When  the  child  begins  to  walk  a  shoe  is  worn  which 
is  raised  f  to  f-  inch  on  the  outer  side. 

The  older  method  of  gradual  correction  in  plaster-splints  demands 
much  time  and  patience,  and  is  seldom  able  to  be  carried  to  the  end. 
So  it  has  been  very  generally  abandoned.  Konig's  plan  of  forcible  cor- 
rection is  used  instead  as  a  rule  and  retention  splints  only  applied  to 
maintain  the  accomplished  result.  A  method  somewhat  intermediate 
between  these  two  procedures  is  that  of  J.  Wolff;  he  applies  a  splint 
with  a  cut  on  the  inner  side  and  a  wedge  removed  on  the  outer  side,  so 
that  the  foot  can  be  moved  and  gradually  corrected  in  the  splint  about 
every  three  days.  The  foot  is  bandaged  in  the  position  attained  after 
each  correction.  When  the  correction  is  complete  the  splint  is  smoothed 
off  and  strengthened  with  strips  of  wood  and  silicate.  The  patient  then 
wears  a  shoe  over  the  splint  for  six  to  nine  months.  The  principle  of 
the  method  is  the  same  as  that  of  the  adjustable  apparatus,  but  the 
splint  fits  better  and  facilitates  more  rapid  correction.  Wolff  lays  the 
greatest  stress  upon  correcting  the  adduction  and  allowing  active  use  of 
the  foot  to  do  the  rest.  If  the  manipulation  is  carried  out  with  the  splint 
on,  the  latter  is  more  apt  to  become  wrinkled  and  produce  decubitus 
than  if  the  manipulation  were  done  previously.  (Konig's  method.) 
Konig  was  the  first  to  use  this  method,  for  the  application  of  which 
valuable  suggestions  have  been  made  recently  by  Lorenz.  It  can  be 
recommended  for  all  cases  up  to  the  twentieth  year. 

Konig's  Method.  Konig  first  divided  the  tendo  Achillis,  and  if 
necessary  the  plantar  aponeurosis,  subcutaneously.  The  author  thinks 
it  is  better  to  divide  the  tendon  after  the  foot  has  been  corrected.  In 
young  children  division  of  the  aponeurosis  is  unnecessary;  in  older 
people  it  is  often  advantageous.  With  the  patient  under  anaesthesia 
and  in  the  lateral  position  the  first  step  is  to  correct  the  adduction  of 
the  front  part  of  the  foot.  The  dorsum  of  the  foot  is  placed  upon  a 
Vol.  III.— 52 


818 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


padded  prism-shaped  wooden  block,  the  inner  side  of  the  heel  grasped 
with  one  hand,  the  front  of  the  foot  with  the  other,  and  with  increasing 


Fig..  518. 


m  ■■ 


Lorenz'  method  of  manual  correction.      Correction  of  varus  deformity. 

Fig.  519. 


Lorenz'  method  of  manual  correction.      Flattening  the  sole. 

force,  and  if  necessary  with  interrupted  pressure,  the  foot  is  gradually 
straightened.     (Fig.  518.)    According  to  Konig  cracking  sounds  should 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 


819 


be  expected  as  the  ligaments  are  torn  and  the  hones  are  broken;  but 
with  Lorenz  the  author  prefers  to  proceed  slowly,  especially  in  the 
case  of  young  children,  in  whom  pressure  by  jerks  is  ineffectual  on 
account  of  the  elasticity  of  the  foot.  In  older  cases,  which  cannot  be 
straightened  by  gradual  pressure,  the  ligaments  can  be  torn  and  the 
bones  broken  by  jerking.  The  skin  should  be  drawn  together  on  the 
inner  side  of  the  foot  previously  to  prevent  its  being  torn.  In  the  ease 
of  children  the  block  may  not  be  necessary,  but  it  is  important  to  grasp 
the  heel  and  ankle  firmly  with  one  hand  to  prevent  fracture  of  the 
malleoli. 

The  second  step  is  to  overcorrect  the  inflexion  of  the  foot,  namely, 
the  cavus  deformity,  until  the  sole  is  convex.     For  this  the  counter- 

Fig.  520. 


Lorenz'  method  of  manual  correction.     Correcting  the  equinus  deformity. 


traction  of  the  tendo  Achillis  is  important,  hence  the  mistake  of  dividing 
the  tendon  previously.  The  fibula  is  liable  to  break  if  the  front  of  the 
foot  is  jerked  or  flexed  too  forcibly.  The  correction  is  facilitated  by 
using  Lorenz'  traction  sling.  (Fig.  519.)  The  third  step  is  to  overcome 
the  equinus  position  of  the  foot  as  a  whole.  One  should  not  be  deceived 
by  the  cushion  of  fat  on  the  heel,  but  ascertain  the  position  of  the 
calcaneum  by  its  tuberosity.  Generally  it  is  necessary  to  divide  the 
tendo  Achillis;  even  then  the  correction  is  often  difficult.  Direct  manip- 
ulation of  the  heel  is  often  required  in  addition  to  forced  flexion  of 
the  tarsus  if  the  foot  is  small  and  elastic.  (Fig.  520.)  Finally,  with  the 
malleoli  well  fixed,  the  foot  should  be  everted  by  rotary  movements  and 


820 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


pressure  made  on  the  outer  border  of  the  calcaneum  to  overcome  the 
valgus  position  of  the  posterior  tarsals. 

If  the  foot  is  properly  corrected,  it  should  be  easily  brought  into  a  pes 
calcaneovalgus  position,  as,  for  example,  by  pulling  upon  the  little  toe. 
Although  the  correction  may  be  accomplished  with  patience  and  per- 
severance in  one  sitting,  it  is  better  to  do  it  by  degrees  at  intervals  of 
two  to  three  weeks.  As  a  rule  the  author  corrects  the  adduction  and 
inflexion  of  the  foot  the  first  time,  and  the  equinus  position  later  after 
dividing  the  tendo  Achillis. 

As  manipulation  is  ineffectual  in  older  patients,  various  apparatus 
have  been  suggested,  the  more  complicated  of  which  have  been  aban- 
doned in  Germany  for  the  simpler  ones,  such  as  the  widely  recommended 
modelleur-osteoclast  of  Lorenz.     (Fig.  521.) 

Fig.  521. 


Lorenz'  modelleur-osteoclast. 

With  Lorenz'  apparatus  the  individual  components  of  the  deformity 
can  be  overcome  by  gradual  traction  and  in  severe  old  cases  corrected 
under  anaesthesia.  Here  again  we  prefer  gradual  correction  in  several 
sittings.  Stille,  the  instrument-maker  in  Stockholm,  has  recently  made 
improvements  in  the  Lorenz  apparatus. 

Considerable  swelling  is  to  be  expected  if  much  force  has  been  used 
in  the  manipulation,  so  that  the  retention  splint  should  not  be  applied  too 
tightly.  The  foot  should  always  be  padded.  If  only  moderate  force 
was  used,  a  plaster-splint  can  be  applied  at  once,  and  the  foot  elevated 
and  kept  under  observation  for  the  first  few  days.  If  the  toes  swell,  the 
splint  can  be  cut  slightly  on  the  dorsum  and  the  edges  bent  up.     After 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        821 

the  swelling  has  subsided  the  retention  splint  is  replaced  by  a  permanent 
one  to  be  worn  for  several  months;  later  massage  and  active  motion  to 
exercise  the  muscles  and  mobilize  the  joint;  or,  a  removable  splint  may 
be  applied  and  massage  begun  earlier. 

Complete  division  of  the  various  tendons  and  ligaments  has  been  sug- 
gested by  a  few  authors  to  facilitate  correction.  The  tendon  of  the 
tibialis  posticus  is  the  one  most  frequently  divided.  The  author  divides 
the  tendo  Aehillis  and  plantar  fascia  if  necessary,  but  never  any  other 
tendons  or  fascia.  Division  of  the  tendo  Aehillis — possibly  also  the 
plantar  fascia — is  generally  necessary  to  complete  the  last  step.  Unless 
the  tendon  lies  close  to  the  bone,  subcutaneous  tenotomy  is  preferable 
to  open  division.  As  it  is  better  not  to  divide  the  deep  fascia  in  the 
sole,  the  aponeurosis  can  also  be  divided  subcutaneously.  Phelps 
recommends  open  division  of  all  the  contracted  tissues  in  the  sole. 
This  method  gives  good  results  and  has  met  with  wide  approval,  but  we 
believe  that  the  cases  rectifiable  by  Phelps'  operation  can  be  corrected  by 
manipulation  followed  by  apparatus.  The  method  is  preferable  to  resec- 
tion in  some  cases,  but  cannot  replace  it  entirely.  The  same  long  after- 
treatment  as  after  manual  correction  is  required  to  prevent  recurrence. 

Subcutaneous  Division  of  the  Tendo  Achillis. — The  tendo 
Aehillis  can  be  divided  subcutaneously  h  to  1  inch  above  its  insertion; 
with  the  child  anesthetized,  the  knee  extended  and  held  by  an  assistant 
and  the  foot  flexed,  a  lance-shaped  or  slightly  curved  tenotome  is  inserted 
on  the  inner  side,  in  front  of  and  parallel  to  the  tendon  with  the  cutting 
edge  facing  the  foot,  until  the  point  is  felt  on  the  outer  side  under  the 
skin;  the  blade  is  then  turned,  and  with  the  thumb  upon  the  skin  behind 
the  tendon  the  latter  is  divided  until  it  gives  suddenly  and  a  distinct 
gap  can  be  felt  between  the  stumps.  Some  surgeons  prefer  to  divide 
it  from  behind  forward  from  the  inner  side,  but  unless  care  is  used 
the  posterior  tibial  artery  can  be  injured.  The  bleeding  is  slight;  a 
small  aseptic  dressing  is  applied  with  pressure  after  correction. 

Of  the  various  operations  on  the  bones  necessary  in  extreme  cases,  the 
following  table  made  by  Lorenz  in  1885  needs  essentially  no  additions: 

A.  Osteotomy. 

1.  Linear  division  of  the  scaphoid  through  the  sole.     (Hahn.) 

2.  Linear  osteotomy  of   the   tibia   and   fibula  above  the  joint. 

(Hahn,  Vincent.) 

B.  Enucleation. 

1.  Of  the  cuboid. 

2.  Of  the  astragalus  (Lund,  Mason):  (a)  with  resection  of  the 

tip  of  the  external  malleolus  (Mason,  Ried);  (b)  with 
removal  of  the  spongiosa  of  the  astragalus,  leaving  its 
articular  surfaces  (Yerebely);  (c)  with  excision  of  a  vertical 
wedge  with  base  outward  from  entire  thickness  of  the  front 
of  the  calcaneum.     (Hahn.) 

3.  Of  the  astragalus  and  cuboid.     (Albert,  Hahn.) 

4.  Of  the  astragalus,  cuboid,  and  scaphoid.      (West.) 

5.  Of  the  scaphoid  and  cuboid.     (Bennet.) 


822 


DISEASES  OF  THE  ASKLE  AND  FOOT. 


C.  Resection. 


1.  Of  the  head  of  the  astragalus.     (Lticke,  Albert.  I 

2.  Of  a  wedge  from  the  outer  half  of  the  neck  of  the  astragalus. 

(Hiiter.) 

3.  Of  wedges   with  base  outward  and  at  right  angles  to  each 

other  from  the  mediotarsal  and  calcaneo-astragaloid  joints. 
(Rydygier.) 

4.  Of  a  wedge  from  the  entire  tarsus.     (O.  Weber,  Da  vies  and 

("oiler,  R.  Daw. 
Excision  of  the  astragalus  and  resection  of  a  wedge  from  the  tarsus 

"ill 

are  the  operations  used  chiefly  at  the  present  time.  As  both  are  some- 
what deforming  they  should  never  be  used  in  young  children  and  only 
in  the  very  severe  old  cases  in  older  people. 

Excision  of  the  Astragalus. — Slightly  curved  incision  from  the 
external  malleolus  over  the  prominence  of  the  astragalus  to  the  outer 
side  of  the  extensor  tendons.     After  lifting  off  the  tendons  of  the  peronei, 


Fig. 


Fig.  523. 


Congenital  club-foot  after  astragalectomy  and  cuneiform  tarsal  resection,  same  as  Plate  XXI. 

(Hartley.) 


which  are  often  displaced  forward,  the  talofibular  ligaments  (and  in  con- 
genital talipes  varus  the  calcaneofibular)  are  divided,  the  head  of  the 
astragalus  is  seized  with  bone-forceps,  and  the  astragalus  extracted 
after  dividing  the  ligaments  in  the  sinus  tarsi  and  the  deltoid  ligament. 
The  various  joints  are  then  mobilized  and  the  adhesions  broken  up 


X 
X 

< 

Ph 


h 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        823 

forcibly,  if  necessary  by  dividing  the  tendo  Achillis  and  the  plantar 
aponeurosis.  Resection  of  a  wedge  from  the  anterior  portion  of  the 
calcaneum  may  be  required.  Division  of  the  connections  between  the 
fibula  and  calcaneum  is  essential  in  order  to  correct  the  position  of 
the  calcaneum.  Complete  resection  of  the  external  malleolus  is  not 
advisable;  it  may  be  rounded  off  to  prevent   pressure  against  the  skin. 

Resection  of  a  Wedge  prom  the  Tarsus. — A  transverse  incision 
is  made  from  the  tuberosity  of  the  scaphoid  passing  over  the  most 
prominent  point  on  the  dorsum  to  the  outer  border  of  the  foot.  In  the 
case  of  paralytic  talipes  varus  two  incisions  parallel  to  the  extensor 
tendons  are  advisable  on  account  of  the  poor  nutrition  of  the  skin.  The 
fascia  is  divided,  the  extensor  tendons  and  the  peronei  lifted  off  with  the 
elevator,  and  the  mediotarsal  joint  exposed.  The  wedge — with  base 
on  the  outer  side  comprising  the  anterior  portion  of  the  calcaneum  and 
part  of  the  astragalus  and  cuboid,  and  with  apex  situated  in  the  inner 
part  of  the  scaphoid,  or  at  the  inner  surface — is  cut  out  with  the  chisel, 
or  with  a  bone-knife  if  the  bones  are  soft.  If  necessary  to  facilitate 
correction,  the  tendon  of  the  tibialis  posticus  maybe  divided.  Excision 
of  a  second  wedge  may  be  required  to  overcome  the  inversion  of  the 
calcaneum. 

In  either  operation  the  correction  must  be  complete  to  prevent  recur- 
rence. Later,  orthopaedic  treatment  continued  for  some  time  and  the 
wearing  of  a  shoe  with  a  side  brace  are  desirable,  although  not  indis- 
pensable if  the  operation  is  effectual.  Comparing  the  two  operations 
it  should  be  noted  that  cuneiform  osteotomy  shortens  the  foot  con- 
siderably and  makes  almost  all  the  tarsal  joints  stiff.  By  excision  of 
the  astragalus  the  foot  is  shortened  and  the  malleoli  lowered.  A  fairly 
movable  joint  may  form  between  the  calcaneum  and  tibia.  Sometimes 
osteotomy  or  cuneiform  resection  are  required  in  addition.  As  a  rule 
compensatory  mobilization  takes  place  in  the  tarsometatarsal  joints  after 
both  operations.  A  choice  between  the  two  operations  depends  chiefly 
upon  whether  the  deformity  involves  principally  the  region  of  Chopart's 
joint  or  the  astragalus  and  calcaneum,  as  otherwise  the  functional 
results  are  equally  good.  Pirogoff's  amputation  is  sometimes  advisable 
in  old  severe  cases  in  older  people,  especially  when  accompanied  by 
suppuration  of  the  accessory  bursas,  pressure  sores  and  suppuration  of 
the  joints. 

In  general,  acquired  talipes  varus  is  more  easily  corrected  than  the 
congenital  form,  unless  it  is  very  old  and  associated  with  deformation 
of  the  bones.  The  prognosis  of  congenital  talipes  varus  depends  upon 
the  amount  of  deformation  of  the  bones  and  joints,  and  becomes  less 
favorable  the  earlier  the  alterations  occurred  in  utero;  the  position  and 
deformation  of  the  calcaneum  and  astragalus  are  especially  significant. 
In  slight  congenital  cases  the  deformity  can  be  overcome  entirely;  in 
the  severed  cases  the  limb  can  still  be  made  useful.  Recovery  may  be 
said  to  be  complete  if  the  foot  can  be  everted  actively  (not  considering 
the  paralytic  and  post-operative  ankylotic  cases),  and  permanent  if  there 
is  no  recurrence  within  six  months.     Active  mobility  is  dependent  not 


824  DISEASES  OF  THE  ANKLE  AND  FOOT. 

only  upon  restoring  the  shape  of  the  foot,  the  bones  and  joints,  but 
also  the  function  of  the  muscles,  especially  the  evertors.  Recurrence 
means  that  treatment  was  discontinued  too  soon;  the  patients  usually 
know  less  about  the  action  of  the  apparatus  than  about  the  function 
of  the  foot,  so  that  the  advisability  of  discharging  the  patient  in  an 
apparatus  before  the  full  function  of  the  foot  is  restored  is  questionable. 
As  a  rule,  particularly  among  the  poorer  classes,  the  apparatus  is 
neglected  or  very  badly  repaired.  In  such  cases  the  recurrence  dates 
from  the  application  of  the  apparatus.  If  recurrence  takes  place, 
constant  wearing  of  an  apparatus,  tendon  transplantation,  or  arthrodesis 
are  inevitable. 

In  paralytic  club-foot  the  above  treatment  can  only  correct  the  de- 
formity; apparatus  must  be  worn  continuously  to  maintain  the  correction. 

Tendon  transplantation  is  to  be  considered  chiefly  for  paralysis  of 
part  of  or  all  the  evertors.  If  only  the  peronei  are  paralyzed,  the  outer 
half  of  the  tendo  Achillis  can  be  split  up  to  the  muscle  and  sutured  to  the 
distal  stumps  of  the  peroneal  tendons.  If  the  extensor  communis  digi- 
torum  is  paralyzed,  the  extensor  hallucis  or  part  of  the  tibialis  anticus 
can  be  sutured  to  the  distal  stump  of  the  divided  extensor  communis. 
The  two  procedures  may  be  combined.  Lange's  periosteal  tendon 
transplantation  is  also  very  useful;  in  v.  Bergmann's  clinic  we  have  split 
the  tibialis  anticus,  drawn  the  outer  half  down  beneath  the  skin  and 
sutured  it  to  the  periosteum  of  the  cuboid  with  good  result.  The 
numerous  varieties  of  transplantation  which  are  practical  and  have  been 
applied  successfully  are  given  in  the  literature.  (Drobnik,  Vulpius,  and 
others.) 

Arthrodesis,  although  capable  of  giving  permanent  results  with  the 
foot  in  a  good  position,  is  nevertheless  being  more  and  more  relin- 
quished in  favor  of  tendon  transplantation,  so  that  it  may  be  said  that 
it  is  indicated  only  in  the  cases  of  paralysis  too  severe  to  be  benefited 
by  tendon  transplantation.  It  is  usually  sufficient  to  stiffen  the  ankle- 
joint,  although  occasionally  Chopart's  joint  or  the  calcaneo-astragaloid 
joint  has  to  be  ankylosed  also.  The  best  incision  is  an  anterior  trans- 
verse or  curved  incision,  through  which  the  tibiotarsal  and  mediotarsal 
joints  are  both  accessible. 

Talipes  Equinus. — The  term  talipes  equinus  is  applied  to  the  deform- 
ity in  which  the  foot  is  fixed  in  extension  and  cannot  be  flexed  to  a  right 
angle.  Strictly  speaking  the  contracture  therefore  affects  only  the  tibio- 
tarsal joint,  in  which  flexion  and  extension  take  place,  although  the 
other  joints  of  the  foot  are  concerned  in  severe  cases.  Pure  talipes 
equinus  is  rarely  congenital,  as  external  forces  acting  upon  the  extended 
foot  in  utero  usually  produce  a  talipes  equinovarus.  Acquired  talipes 
equinus,  although  a  rather  common  deformity,  is  less  frequent  than 
congenital  talipes  varus;  its  etiology  is  very  similar  to  that  of  the  latter. 
Paralysis  is  the  most  common  cause.  The  contracture  develops  most 
rapidly  if  only  the  dorsal  flexors  are  paralyzed;  but  even  if  all  the 
muscles  are  paralyzed,  the  foot  drops  by  its  own  weight  unless  pre- 
vented by  being  used  in  walking.       As  the  foot  usually  also  becomes 


CONTRACTURES  AND  DEFORMITIES  OF  THE  Fool'. 


825 


bent  in  the  mediotarsal  and  tarsometatarsal 
joints,  it  is  likewise  adducted  and  inverted 
(talipes  equinovarus). 

Talipes  equinovalgus  (pes  valgo-equinus; 
tains  pied  erenx,  valgus  de  I'avantpied,  Duch- 
enne)  is  rare,  and  occurs  occasionally  after 
paralysis  of  the  tibialis  anticus  alone.  The 
extensor  digitonun  cannot  by  itself  prevent 
the  equinus  position,  but  as  it  is  stronger  than 
the  extensor  hallucis  it  abducts  and  everts  the 
front  part  of  the  foot.  The  foot  is  everted 
still  more  by  the  peronei  if  the  extensors  are 
paralyzed. 

The  position  of  the  toes  varies.  If  the 
tibialis  anticus  alone  is  paralyzed,  the  toes  are 
usually  extended  actively  to  flex  the  foot  as 
much  as  possible  and  so  assume  a  claw-posi- 


Fig.  524. 


Talipes  cavo-equinus  and  claw- 
toe  from  paralysis  of  the  tibialis 
anticus.    (Duchenne.) 


Fig.  525. 


Different  degrees  of  talipes  equinus  paralyticus.     (Adams.) 


tion.  (Fig.  524.)  This  is  increased  by  walking  on  the  ball  of  the  foot. 
Even  if  the  extensors  of  the  toes  are  paralyzed,  the  toes  may  be  forced 
into  the  same  position  by  the  weight  being  thrown  on  the  ball  of  the  foot. 


326  DISEASES  OF  THE  ANKLE  AND  FOOT. 

In  extreme  cases  they  may  become  subluxated.  If,  after  paralysis  of  the 
extensors,  a  marked  talipes  equinus  develops  before  the  patient  learns  to 
walk,  the  toes  may  become  flexed.  The  patient  then  walks  upon  the 
dorsal  surface  of  the  toes,  or  the  dorsum  of  the  foot,  or  even  the  trochlea 
of  the  astragalus.  As  a  rule  in  these  cases  the  foot  is  also  more  or  less 
in  the  varus  position.     (Fig.  525.) 

In  almost  all  cases  of  talipes  equinus  the  arch  of  the  foot  is  increased. 
If  the  foot  is  not  used,  this  is  due  to  the  action  of  the  antagonists  and  the 
weight  of  the  front  of  the  foot;  and  if  used,  it  is  due  to  the  patient's 
effort  to  increase  the  equinus  position,  so  that  the  foot  can  be  used  as  a 
stilt  without  taxing  the  muscle  of  the  calf  unduly.  If  the  equinus 
position  is  very  marked,  the  arch  is  increased  by  the  body-weight  and 
the  foot  appears  shortened. 

Neuropathic  spastic  talipes  equinus  occurs  with  spastic  acampsia, 
hysteria,  pressure  myelitis,  and  cerebral  paralyses.  At  first  it  may  be 
intermittent,  but  usually  becomes  permanent  in  time. 

Of  the  various  other  pathological  processes  which  likewise  produce 
talipes  equinus,  in  much  the  same  way  that  they  produce  talipes  varus, 
we  should  mention :  cicatricial  contraction  of  the  skin  of  the  calf,  shrink- 
age of  the  calf  muscles  following  purulent  or  non-purulent  inflamma- 
tions, fractures  of  the  malleoli  and  in  the  tibiotarsal  joint  uniting  with 
deformity,  non-traumatic  deformities  of  the  bones,  such  as  hyperostoses, 
etc.,  ankylosis  following  inflammation  of  the  tibiotarsal  joint.  Talipes 
equinus,  like  talipes  varus,  is  also  frequently  a  contracture  by  habit. 
It  is  seen  in  bedridden,  feeble  patients;  also  as  the  result  of  faulty 
immobilization,  or  of  walking  on  the  toes  for  years  to  compensate  short- 
ening of  the  limb,  or  to  prevent  the  discomfort  of  some  painful  affection 
of  the  heel. 

Symptoms. — The  limb  is  lengthened;  to  compensate  this  the  knee  is 
flexed  and  the  pelvis  elevated.  The  gait  is  stiff  and  somewhat  of  a  hop- 
ping character.  The  leg  is  swung  outward  at  each  step  in  order  to  clear 
the  ground  with  the  front  of  the  foot.  This  is  most  pronounced  in  the 
paralytic  form.  If  the  limb  is  shortened  by  atrophy,  the  gait  is  more 
limping  than  hopping.  If  the  condition  is  bilateral,  the  patient  generally 
has  to  use  a  cane  or  crutches.  Usually  the  foot  becomes  fatigued  easily. 
Walking  for  any  length  of  time  often  produces  pain  in  the  tarsus  and 
the  metatarsophalangeal  joints.  Thick  callosities  usually  form  over 
the  heads  of  the  metatarsals  and  may  be  very  painful. 

Pathological  Anatomy. — In  mild  cases  the  skeletal  changes  are  insig- 
nificant. The  essential  of  the  deformity  is  the  extension  of  the  astragalus 
and  calcaneum,  which  is  not  in  excess  of  the  normal,  but  cannot  be  over- 
come on  account  of  the  shortening  of  the  soft  parts.  In  more  severe 
cases  subluxation  may  take  place  in  the  tibiotarsal  joint,  so  that  the 
astragalus  articulates  with  the  tibia  and  fibula  only  by  the  posterior 
part  of  the  trochlea;  on  this  portion  the  articular  surface  is  lengthened 
and  the  bone  is  flattened.  (Fig-  526.)  The  cartilage  in  front  is  more 
or  less  atrophic  and  occasionally  replaced  by  abnormal  thickening  of 
the  bone.     The  articular  surface  of  the  head  projects  into  the  dorsum 


CONTRACTS  11  US  .  1  A  I)  DFFOR M I Tl ES  OF  THE  FO O T. 


827 


.mid  is  worn  off  obliquely  below.  The  scaphoid  and  cuboid  arc  sub- 
luxated  toward  the  sole.  The  calcaneum  is  extended  sharply  with  the 
astragalus  and  may  articulate  with  the  posterior  border  of  the  tibia  or 
the  external  malleolus.  The  smaller  tarsal  bones  are  usually  more 
wedge-shaped,  like  the  stones  of  an  arch.  All  these  changes  are  modi- 
lied  according  as  to  whether  the  patient  walks  on  the  dorsum  or  the  sole 
of  the  foot  with  the  toes  sharply  extended;  if  on  the  sole,  the  toes  are 
subluxated  backward  on  the  metatarsals.  (Fig.  526.)  The  heads  of 
the  metatarsals  then  project  forward  and  support  the  weight  of  the 
body. 

Fig.  526. 


Old  talipes  equinus.      (v.  Bruns.) 

The  capsules  and  ligaments  are  stretched  on  the  convex  side  and 
shortened  on  the  concave  side  of  the  foot.  Of  the  muscles,  the  gas- 
trocnemius is  shortened  the  most,  the  others  of  the  calf  less  so.  The 
short  plantar  muscles  are  markedly  retracted. 

Treatment. — The  treatment  of  talipes  equinus  is  very  similar  to  that 
of  talipes  varus,  namely:  in  mild  cases,  manipulation,  massage,  and 
exercises;  in  severe  cases,  division  of  the  tendo  Achillis,  forcible  cor- 
rection in  several  stages,  and  in  the  intervals  immobilization.  Numerous 
apparatus  are  used  to  effect  gradual  correction;  in  some  the  patient 


828 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


flexes  the  foot  passively,  as,  for  example,  with  Bonnet's  apparatus. 
Many  modern  medico-mechanical  apparatus  are  similar  but  more 
effectual.  Elastic  traction  is  easily  applied  by  means  of  Heidenhain's 
contrivance,  which  consists  of  a  strap  and  buckle  passed  above  and 
below  through  two  rubber  rings,  attached  in  turn  below  to  a  loop 
passing  under  a  sole  plate  at  the  ball  of  the  foot,  and  above  to  adhesive- 
plaster  strips  on  the  thigh.  (Fig.  527.)  The  elastic  traction  can  also 
be  attached  to  a  jointed  plaster-splint. 

There  are  very  many  portable  apparatus  acting  by  means  of  elastic 
traction,  examples  of  which  are  given  in  Figs.  528  and  529.  Hessing's 
more  expensive  apparatus  is  to  be  recommended  for  those  who  can 
afford  it.     These  portable  apparatus  are  applicable  in  mild  cases  not 


Fig.  527. 


Fig.  528. 


Fig.  529. 


Heidenhain's  traction  loop  for 
talipes  equinus. 


Hudson's  apparatus. 


Goldschmidt's  apparatus. 


requiring  previous  correction,  and  for  such  are  the  most  comfortable 
methods  of  treatment.  They  are  especially  useful  for  the  paralytic 
cases  which  always  require  permanent  support  to  prevent  recurrence. 

Old  cases  in  which  the  dislocated  astragalus  is  too  wide  to  be  reduced, 
necessitate  removal  of  the  astragalus,  or  part  of  the  same  and  of  the 
malleoli.  If  the  ankle-joint  is  ankvlosed,  supramalleolar  osteotomy 
or  partial  resection  of  the  joint  may  be  necessary.  In  mild  cases 
walking  is  facilitated  by  supporting  the  heel.  In  paralytic  cases, 
if  the  paralysis  is  limited,  tendon  transplantation  is  indicated,  other- 
wise arthrodesis  is  preferable.  Or  if  shortening  of  the  limb  exists  at 
the  same  time,  Wladimiroff  and  Mikulicz'  resection  has  been  performed 
instead  of  arthrodesis  in  order  to  lengthen  the  limb.  (v.  Bruns.)  In 
the  spastic  cases  division  of  the  tendo  Achillis  or  transplantation  of  the 


CONTRACTURES  AM)  DEFORMITIES  OF  THE  FOOT. 


829 


plantar  flexors  into  the  dorsal  flexors  should  be  tried.  In  severe  cases 
a  talipes  cavus  is  sometimes  left  after  overcoming  the  extension;  it 
requires  treatment  if  it  does  not  disappear  of  itself.    (See  Talipes  Cavus.) 

Flat-foot  iTalipes  Valgus).  —By  flat-foot  the  author  understands 
the  deformity  in  which  the  foot  is  fixed  in  eversion  and  abduction.  A 
congenita]  and  acquired  form  can  he  distinguished  as  in  talipes  varus. 

Etiology. — The  statistics  as  to  the  frequency  of  congenital  flat-foot 
vary  within  wide  limits.  HofTa  estimates  that  only  4.3  per  cent,  of  all 
eases  are  congenital.  Kustner— to  whom  we  are  indebted  for  the  most 
detailed  description  of  the  congenital  form — found  15  Hat  feet  in  300 — 
that  is,  in  150  children,  who  had  to  be  carried  hut  were  otherwise  healthy 
(5  per  cent.). 

According  to  the  prevalent  idea,  the  foot  in  the  newborn  is  almost 
always  Hat.  As  noted  by  Hiiter,  the  arch  does  not  develop  till  after 
birth.     As  the  layer  of  subcutaneous  fat  is  relatively  thick  in  the  sole  of 


Fig.  530. 


Fig.  531. 


Congenital  flat-foot.     (Kustner.) 


the  newborn  and  the  bones  and  ligaments  are  extremely  yielding,  a 
decision  as  to  the  presence  or  absence  of  flat-foot  cannot  always  be 
made,  as  emphasized  by  Kustner,  from  footprints  or  foot-tracings  of 
charcoal  upon  glass.  Therefore  Kustner  designated  as  flat-foot  the 
cases  giving  the  following  symptom-complex:  The  sole  is  distinctly 
convex  and  the  foot  is  accordingly  longer;  if  the  condition  is  unilateral, 
this  lengthening  can  be  verified/  The  dorsum  of  the  foot  is  concave; 
over  it  the  skin  is  thrown  into  folds,  whereas  on  the  sole  the  normal  folds 
are  less  distinct.  (Fig.  530.)  A  depression  is  found  below  the  middle 
of  the  leg  at  the  outer  side  of  the  tibia,  into  which  the  foot  fitted.  The 
leg  is  thinner  than  normal  in  this  region.  (Fig.  531.)  The  description 
given  by  Kustner  applies  very  closely  to  congenital  talipes  calcaneus, 
except  that  in  the  latter  the  extension  of  the  foot  is  not  always  so  pro- 
nounced as  it  was  in  Kiistner's  cases,  but  the  eversion  and  abduction  of 
the  front  of  the  foot  more  so,  so  that  the  foot  is  bent  sharply  outward 
at  Chopart's  joint;  the  toes  are  extended  or  clawed.     (Fio-.  532.) 


830 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


Fig.  532. 


Congenital  talipes  calcaneo 
valgus,      (v.  Volkinann.) 


The  cause  of  congenital  flat-foot  is  without  doubt  usually  that  the 
foot  becomes  fixed  in  the  abnormal  position  in  utero.  At  the  same 
time  the  knee  may  be  flexed  sharply,  or  the  extended  limb  may  be  flexed 
upon  the  abdomen,  or  the  feet  may  be  interlocked.  (See  under  Talipes 
Varus.)  This  fixation  is  certainly  largely  due  to  relative  lack  of 
space  and  of  amniotic  fluid.  Further  causes  are  defects  of  the  fibula 
(Volkmann's  "maldevelopment  of  the  ankle-joint"),  diseases  of  the 
central  nervous  system  (congenital  paralytic 
talipes  valgus),  and  foetal  rhachitis.  (Schul- 
theiss.)  The  calcaneum  has  been  found  adhe- 
rent to  the  scaphoid  or  astragalus  in  some  cases. 
(Holl.)  Franke  refers  many  cases  to  maldevelop- 
ment— primary  disturbances  of  growth — and  to 
abnormal  insertion  of  the  muscles.  In  one  in- 
stance in  which  the  foot  was  very  flabby  he 
found  the  tendon  of  the  tibialis  anticus  inserted 
on  the  dorsum  of  the  foot;  improvement  was 
obtained  by  shortening  and  shifting  the  tendon. 
The  acquired  form  of  flat-floot  may  be  due  to 
rhachitis.  As  is  known,  the  weight  of  the  body 
tends  to  evert  the  foot;  if  the  bones  are  abnor- 
mally soft,  they  yield  and  become  shaped  in  the 
direction  of  e  version.  Curvatures  of  the  tibia 
and  fibula  often  favor  the  valgus  position,  but 
the  abduction  of  the  rhachitic  flat-foot  is  not 
always  so  marked  as  in  the  static  form  acquired  later;  more  often  the 
arch  is  flattened — that  is,  the  condition  is  flattened  foot  [weak-foot  of 
Whitman]  rather  than  talipes  valgus. 

Flat-foot  also  develops  after  paralysis,  especially  in  children.  Flere 
again  it  is  usually  the  weight  of  the  body  which  everts  and  abducts  the 
foot.  It  follows  most  rapidly  if  the  plantar  flexors  and  invertors  of  the 
foot  alone  are  affected;  but  it  also  occurs  after  complete  paralysis  of 
the  foot.  The  ankle-joint  is  extended,  the  mediotarsal  joint  everted. 
When  not  in  use  and  in  the  recumbent  position  the  foot  is  extended 
and  inverted  by  its  own  weight,  and  as  a  result  becomes  abnormally 
movable,  even  a  flail-foot.  Very  exceptionally  paralytic  flat-foot  develops, 
during  disuse,  after  paralysis  of  the  plantar  flexors  and  invertors  of  the 
foot,  from  the  active  contraction  of  the  evertors.  The  ankle-joint  is  then 
flexed  at  first  and  gradually  becomes  extended  after  the  foot  is  used. 
Occasionally  in  such  cases,  if  the  patient  does  not  walk  upon  the  foot, 
the  back  part  of  the  foot  becomes  strongly  abducted  and  everted,  while 
the  front  of  the  foot  is  extended  by  its  own  weight. 

Traumatic  flat-foot  may  develop  after  fractures,  dislocations,  or 
injury  of  the  tibialis  anticus  and  the  long  flexors  of  the  toes.  (Vul- 
pius.)  It  is  most  commonly  the  result  of  fracture  of  the  malleoli 
uniting  with  deformity. 

Static  Flat-foot. — The  most  important  of  the  acquired  forms  of  flat- 
foot  is  the  static  flat-foot  (pes  valgus  staticus  or  adolescentium).     The 


CONTRACTURES  AM>  DEFORMITIES  OF  THE  FOOT.         *:;] 

terms  static  and  adolescentium  are  used  because  the  chief  cause  is  the 
improper  weighting  of  the  foot  (tarsalgia  of  adolescents,  Gosselin)  and 
because  il  develops  most  frequently  during  or  soon  after  puberty. 

Mechanism  of  Origin  of  Static  Flat-foot. — The  function  of  the  foot  is  that 
of  a  supporting  arch,  the  weight  of  the  body  resting  upon  the  astragalus. 
As  the  skeletal  elements  of  the  foot  do  not  form  a  solid  unit,  hut  are 
movable  upon  each  other  and  act  as  an  arch  only  in  certain  positions,  the 
latter  is  merely  a  so-called  bowstring  arch.  The  ligaments  which  tra- 
verse the  entire  arch  in  the  direction  of  the  tendons  and  hind  together 
various  portions  in  the  same  direction,  form  the  main  resistance  in  pre- 
venting the  arch  from  sinking.  Such  a  structure  is  capable  of  move- 
ment within  itself  and  also  of  becoming  stable  when  the  ligaments  are 
put  upon  the  stretch,  provided  that  the  edges  of  the  individual  elements 
on  the  convexity  of  the  arch  support  each  other.  The  factors  concerned 
in  this  resistance  are:  1.  The  tensile  resistance  (absolute  strength) 
of  the  ligaments.  2.  The  incompressibility  (retroactive  resistance)  of 
the  bones.  The  muscles  can  also  contribute  to  the  tensile  strength  of 
the  arch,  and  ordinarily  do  this,  but  not  to  the  extent  formerly  supposed. 

Fig.  533. 


The  main  supports  of  the  foot,  according  to  H.  v.  Meyer. 

According  to  H.  v.  Meyer,  the  arch  of  the  foot  is  supported  in  front 
mainly  by  the  head  of  the  third  metatarsal,  behind  by  the  calcaneum, 
and  is  made  up  essentially  of  the  third  metatarsal  and  its  cuneiform, 
the  cuboid,  and  calcaneum.  (Fig.  533.)  The  joint  between  the  third 
cuneiform  and  the  cuboid  is  the  weakest  point  of  the  arch,  as  it  deviates 
only  45  degrees  from  the  curved  plane  of  the  arch  instead  of  being  per- 
pendicular to  it.  The  resulting  side  strain,  however,  is  transmitted  to 
and  resisted  in  turn  by  the  scaphoid,  astragalus,  and  calcaneum.  From 
the  astragalus  the  wTeight  of  the  body  is  transmitted  to  the  calcaneum 
and  third  metatarsal  through  the  front  of  the  calcaneum  and  cuboid 
and  through  the  scaphoid.  The  lateral  pressure  at  the  front  of  the  arch 
is  distributed  over  a  circle  formed  by  the  cuboid,  base  of  the  third  meta- 
tarsal, third  cuneiform,  and  scaphoid,  the  strength  of  the  transverse 
arch  of  the  front  part  of  the  metatarsals  depending  upon  the  transverse 
ligaments.     If  the  weight  of  the  body  falls  to  the  inner  side  of  the  third 


832 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


toe,  it  is  supported  by  the  three  inner  toes,  and  if  to  the  outer  side,  by 
the  three  outer  toes. 

According  to  the  statistics,  the  static  flat-foot  develops  between  the 
sixteenth  and  twentieth  year  in  by  far  the  greater  number  of  cases.  It 
is  found  chiefly  in  delicate,  rapidly  growing  individuals  with  weak 
muscles  who  are  obliged  to  do  hard  work,  especially  to  stand  or  walk 
for  long  periods — namely,  bakers,  waiters,  locksmiths,  factory-hands, 
servants,  errand-boys,  porters,  etc.  It  occurs  therefore  in  the  class  of 
patients  in  which  genu  valgum  is  most  frequent.  It  is  seen  also  occa- 
sionally in  well-developed  individuals  who  carry  heavy  weights  or  who 
become  rapidly  corpulent,  especially  women.  It  is  due  essentially 
therefore  to  a  disparity  between  the  power  of  resistance  of  the  foot  and 
the  demands  made  upon  it. 

A  Fig.  534.  b 


a  b  c.  Triangle  of  the  foot.  A.  Projection  of  mid-point  of  astragalus,  a  c.  Line  of  great  toe. 
cb.  Line  of  little  toe.  a  b.  Line  of  metatarsus.  A  d.  Distance  of  the  mid-point  of  astragalus  (in 
the  projection)  from  the  line  of  great  toe.  A  e.  Distance  from  line  of  little  toe.  A  a,  A  b,  Ac. 
Projection  of  lines  from  the  angles  of  the  foot  triangle  to  the  mid-point  of  astragalus.  A  a.  Line 
of  support  to  the  great  toe.  A  b.  Line  of  support  to  the  little  toe.  A  c.  Line  of  support  to  the 
heel.     A  a.  Middle  line  of  the  foot.     A  P.  Plane  of  flexion  of  the  trochlea.     (H.  v.  Meyer.) 


For  the  production  of  flat-foot  Henke  assumes  a  relaxation  of  the 
muscles  as  the  primary  cause;  Hiiter,  an  inequality  in  the  growth  of  the 
bones;  Stromeyer,  atony  of  the  plantar  fascia  and  ligaments;  Le  Forte 
and  Tillaux,  weakening  and  stretching  of  the  same;  Lorenz,  a  primary 
weakening  of  an  outer  arch  which  supports  the  inner  arch  and  astrag- 
alus, and  secondarily  of  the  inner  arch.  v.  Meyer  denies  the  sinking  of 
the  arch  as  the  plantar  ligaments  are  not  lengthened,  the  joints  are  not 
separated  and  the  inner  border  of  the  foot  is  not  lengthened  but  normal, 
while  the  outer  border  of  the  foot  is  shortened;  the  chief  cause  is  the 
valgus  position.  In  the  normal  foot  a  vertical  projection  of  the  middle 
point,  namely,  the  trochlea  of  the  astragalus,  falls  in  the  triangle  of  the 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 


833 


foot  formed  by  the  middle  point  of  the  heel  and  tin-  heads  of  the  first 
and  fifth  metatarsals.  (Fig.  534,  A.)  In  flat-foot  this  projection  falls 
to  the  inner  side  of  the  triangle  (Fig.  .">:>4,  b),  and  at  the  same  time 
the  middle  point  of  the  trochlea  of  the  astragalus  approaches  the 
ground.  (Fig.  535.)  In  the  oases  examined  by  v.  Meyer  the  average 
valgus  deviation  of  the  foot  from  the  axis  of  the  trochlea  was  45 
degrees. 

In  flat-foot  therefore  the  arch  does  not  sink  downward  hut  inward. 
By  the  weight  of  the  body  the  astragalus  is  pressed  downward  and  for- 
ward upon  the  calcaneum  and  at  the  same  time  rotated  inward  about 
the  oblique  axis  of  the  calcaneo-astragaloid  joint.  The  outer  end  of 
the  transverse  axis  of  the  trochlea  (in  the  ankle-joint)  thus  becomes 
lowered.  The  beginning  of  flat-foot  is  an  exaggeration  of  this  motion ; 
in  other  words,  excessive  rotation  of  the  astragalus.  The  more  the 
astragalus  sinks  and  the  head  is  rotated  inwTard,  the  more  the  outer 

Fig.  535. 


dA  & 


A  A.   Line  of  vertical  projection  of  mid-point  of  astragalus. 


end  of  the  transverse  axis  becomes  depressed.  This  transverse  axis 
thus  assumes  an  oblique  position  with  respect  to  the  other  tarsals, 
but  as  it  must  remain  horizontal  in  the  ankle-joint,  this  means  that 
the  foot  is  rotated  outward  and  everted  on  the  astragalus.  Hence 
the  line  of  gravity  falls  more  and  more  to  the  inner  side  of  the  foot. 
In  reality  therefore  the  astragalus  remains  at  rest  while  the  foot  deviates 
outward.  The  more  the  calcaneum  deviates  outward,  the  more  the 
sustentaculum  slips  outward  and  forward  under  the  head  of  the 
astragalus  toward  the  line  of  gravity  and  is  pressed  downward, 
while  the  body  of  the  calcaneum  is  pushed  upward  and  backward  by 
the  counterpressure  of  the  ground.  As  any  backward  deviation  of  the 
calcaneum  is  checked  by  the  calcaneofibular  fasciculus  of  the  external 
lateral  ligament,  the  bone  is  forced  upward  behind  and  downward  in 
front  by  the  forward  and  inward  rotation  of  the  fibula  with  the  astrag- 
alus. The  arch  of  the  foot  thus  becomes  flattened.  This  rotation  of 
the  calcaneum  on  the  astragalus  and  leg  can  only  take  place  if  the  ankle- 
Vol.  III.— 53 


834 


DISEASES  OF  THE  ANKLE  AXD  FOOT. 


joint  is  extended  (pes  flexus  [extensus]  Henke).  But  as  the  front  of  the 
foot  cannot  be  extended  when  on  the  ground  the  extension  takes  place 
in  Chopart's  joint.  The  head  of  the  astragalus  rotating  inward  and 
forward  pushes  the  scaphoid,  which  is  firmly  united  to  the  calcaneum, 
forward  and  outward,  and  this  pressure  transmitted  to  the  cuneiforms 
and  cuboid  forces  that  part  of  the  foot  in  front  of  Chopart's  joint  out- 
ward (pes  abductus,  Henke).  v.  Meyer  (and  Lorenz)  agrees  with  Henke 
as  to  the  nature  of  the  subluxation  taking  place  in  the  joints,  but  explains 
the  mechanism  differently.  He  regards  the  extension  of  the  ankle- 
joint  as  the  result,  not  of  active  contraction  of  the  calf  muscles,  but  of 
the  valgus  position  and  the  sinking  (reflexion)  of  the  front  of  the  calca- 
neum. Henke,  Lorenz,  and  v.  Meyer  agree  in  assuming  that  flat-foot  is 
due  to  excessive  eversion  and  abduction.  According  to  v.  Meyer,  the 
shifting  of  the  joint-surfaces  upon  each  other  takes  place  by  gradual 
remodelling  of  the  bones  accompanied  by  stretching  and  possibly 
partial  tearing  of  the  ligaments. 

Fig.  536. 


Outer  view  of  flat-foot.     (Lorenz.) 


Every  time  the  foot  is  overweighted  the  astragalus  is  rotated  down- 
ward and  inward,  and  if  this  is  repeated  often  enough  the  bones  yield, 
the  ligaments  become  stretched,  and  the  valgus  position  follows.  Im- 
proper weighting  of  the  foot  is  even  more  important  than  overweight- 
ing. This  happens  if  the  foot  is  turned  outward  in  walking;  for  in 
order  to  extend  the  foot  the  astragalus  then  has  to  be  rotated  inward 
abnormally.  The  improper  attitude  which  a  tired  person  is  apt  to 
assume,  the  "habitual"  posture  of  Hoffa,  "the  attitude  of  rest"  of 
Armandale,  contributes  even  more  largely  to  alter  the  direction  of 
pressure.  The  legs  may  be  spread  apart  with  the  knees  slightly  flexed 
and  the  feet  turned  outward;  or  the  person  leans  against  a  wall  with 
the  feet  turned  outward  and  planted  well  forward,  a  position  frequently 
assumed  by  waiters  who  go  to  sleep  while  standing.  In  these  postures 
the  weight  falls  to  the  inner  side  of  the  foot,  which  becomes  more  and 
more  abducted  and  everted.  Directly  or  indirectly  this  tends  gradually 
to  stretch  the  ligaments  and  alter  the  shape  of  the  bones.     Such  changes 


CONTRACTURES  AND  DEFORMITIES  OF  THE  /nor. 


835 


can  unquestionably  take  plate  in  bones  of  normal  solidity,  but  the 
coexistence  of  coxa  vara,  genu  valgum,  and  talipes  valgus  in  the  same 
person  and  the  frequent  occurrence  of  the  two  latter  under  the  same 
conditions  of  life  would   seem   to  indicate  a   certain   predisposition. 

Pathological  Anatomy. — The    changes   in   the   bones   and    soft    parts 
have  been  described  most  accurately  by  Lorenz,  with  whose  description 

Fig.  537. 


Inner  view  of  flat-foot.    (Lorenz.) 

v.  Meyer,  Symington  and  others  agree  in  essentials.  The  tip  of  the  exter- 
nal malleolus  is  rounded  and  flattened;  in  severe  cases  the  malleolus  is 
broadened  and  the  tip  bent  out  by  the  pressure  of  the  calcaneum.  (Fig. 
536.)  The  astragalus  is  extended,  so  that  only  the  posterior  part  of  the 
trochlea  articulates  with  the  tibia  and  fibula.  (Fig.  537.)  The  car- 
tilage on  the  anterior  portion  is  atrophic  or  absent;  also  on  the  front 

Fig.  538. 


Astragalus  of  flat-foot.     (Lorenz.) 


portion  of  the  lateral  facets.  The  head  projects  forward  and  down- 
ward, and  the  scaphoid  is  displaced  outward  upon  it.  In  very  severe 
cases  the  scaphoid  may  be  dislocated  upward  upon  it  and  even  articu- 
late with  the  body  of  the  astragalus  by  a  new  joint.  In  other  cases 
there  is  new  growth  of  bone  and  periosteum  on  the  upper  outer  surface 
of  the  head  of  the  astragalus  (Fig.  538)  preventing  further  displacement 


836 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


of  the  scaphoid.  On  the  under  surface  of  the  astragalus  the  changes 
are  less  important,  although  the  cartilage  on  the  under  surface  of  the 
head  may  be  obliterated  if  it  no  longer  articulates  with  the  sustentacu- 
lum. ( Fig.  539.)  On  the  calcaneum  the  cartilage  disappears  from 
the  outer  half  of  the  posterior  margin  where  it  is  no  longer  in  contact 
with  the  astragalus.  The  facet  on  the  sustentaculum  gradually  disap- 
pears. A  hollow  facet  may  form  on  the  inner,  upper  edge  of  the  neck 
to  articulate  with  the  scaphoid.  The  cuboid  becomes  more  wedge- 
shaped.  The  outer  sagittal  diameter  of  the  scaphoid  may  be  so  decreased 
that  the  bone  forms  a  wedge  with  apex  upward  and  outward.  If  the 
scaphoid  is  displaced  upward  and  outward  on  the  astragalus,  the 
cartilage  on  the  posterior  surface  is  present  only  on  the  lower  inner 
portion.     Above,  the  denuded  bone  is  roughened  and  articulates  with 

Fig.  539. 


Astragalus  and  os  calcis  of  flat-foot:  a,  line  of  junction  of  intact  cartilage  c,  and  denuded 
surface  6,  on  the  trochlea.  The  sustentaculum  e  lies  opposite  the  sulcus  tali  instead  of  the 
articular  facet  d.     (Lorenz.) 


a  new  facet  on  the  body  of  the  astragalus  and  neck  of  the  calcaneum. 
The  facets  for  the  cuneiforms  on  the  anterior  surface  of  the  scaphoid 
are  displaced  upward  and  outward.  The  changes  in  the  cuneiforms 
and  metatarsals  are  insignificant.  The  plantar  ligaments,  according  to 
Lorenz,  are  lengthened  and,  for  the  most  part,  thickened  and  hyper- 
trophic. The  external  calcaneo-astragaloid  ligament  is  appreciably 
lengthened  (1  inch  instead  of  f^  inch).  By  subluxation  of  the  scaphoid 
it  may  become  wedged  between  the  astragalus,  calcaneum  and  scaphoid, 
and  destroyed.  The  calcaneo-fibular  fasciculus  of  the  external  lateral 
ligament  may  be  lengthened,  or  destroyed  by  the  nearthrosis  between 
the  fibula  and  calcaneum.  The  combined  deltoid  and  navicular  (lig. 
tibiocalcaneo  naviculare)  ligaments  are  stretched  (If  to  2|  inch, 
instead  of  normal  If  inch),  as  demonstrated  by  Symington;  also  the 
[long]  calcaneocuboid  ligament. 

The  sharp  contrast  between  these  data  and  v.  Meyer's  assertion  that 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        837 

the  plantar  ligaments  are  not  lengthened  is  Lessened  by  the  admission 
of  Lorenz  that  the  sinking  of  the  arch  is  due  "to  pressure  atrophy  of 
the  dorsal  ligaments  on  the  wedge-shaped  bones  of  the  arch,"  and 
that  of  v.  Meyer  thai  there  i-  ;i  secondary  stretching  of  the  ligaments 
favoring  increase  of  the  deformity.  The  changes  in  the  muscles  are 
disregarded  by  recent  authors. 

Flat-foot,  or  talipes  valgus,  is  to  lie  sharply  distinguished  from  pes 
planus.  In  both  deformities  the  sole  is  flattened  and  the  scaphoid 
abnormally  low,  but  in  pes  planus,  which  is  merely  lowering  of  the 
normal  arch,  the  valgus  position  or  pathological  eversion  and  abduction 
of  the  foot  are  absent.  Some  authors  regard  pes  planus  as  an  indication 
of  arrested  development  or  racial  peculiarity  (negroes,  Jews);  others 
believe  that  it  is  due  to  overweighting.  Pes  planus  does  not  pre- 
dispose to  pes  valgus  and  is  usually  not  troublesome.     The   amount 

Fig.  540. 


--'">-. 


«r  ,  ■-  Ss* 


il 


\     '   m 
Footprints  in  flat-foot.    (v.  Voikmann.) 


of  flattening  can  be  ascertained  approximately  according  to  v.  Voik- 
mann by  making  a  charcoal  impression  of  the  foot  (Fig.  540)  or  by 
having  the  patient  make  footprints  on  the  floor.  For  scientific  purposes 
these  methods  are  inaccurate,  as  they  disregard  the  relation  of  the  foot 
to  the  leg. 

Symptoms  and  Diagnosis. — In  recent  cases  the  differentiation  of  the 
various  forms  of  flat-foot  is  not  difficult.  Congenital  flat-foot  is  easilv 
recognized  from  the  above  description,  at  least  in  children;  also  the 
rhachitic  form,  which  is  usually  accompanied  by  other  symptoms  of  the 
disease  and  furthermore  produces  little  disturbance.  The  child  may 
tire  easily  and  exceptionally  complain  of  slight  pain  which  disappears 
with  rest.  There  is  never  any  actual  contracture  or  fixation  such  as  is 
seen  in  the  static  form.  In  older  cases  in  which  the  congenital  merges 
into  the  static  form  the  differentiation  of  the  two  is  more  difficult.  The 
paralytic  form  is  distinguishable  by  the  history,  the  paralysis  and  atrophy 


838 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


Fig.  541. 


of  the  muscle,  the  looseness  of  the  joints,  and  the  facility  with  which  the 
deformity  can  be  corrected. 

The  symptoms  of  traumatic  flat-foot  vary  according  to  the  nature  of 
the  injury.  The  diagnosis  is  usually  easy  from  the  history  and  local 
conditions;  it  is  more  difficult  if  displacement  of  the  bones  or  laceration 
of  the  ligaments  was  slight  and  the  flat-foot  existed  primarily  or  devel- 
oped soon  afterward.      In  a  case  of   well-marked  static  flat-foot  the 

symptoms  are  characteristic.  Viewed  from 
behind,  the  foot  is  seen  to  be  abducted  and 
everted,  the  prolonged  axis  of  the  leg  passes 
through  or  to  the  inner  side  of  the  inner  bor- 
der of  the  foot;  the  internal  malleolus  projects 
prominently.  (Fig-  541.)  The  outward  de- 
viation of  the  entire  foot  if  marked  may  resem- 
ble outward  displacement  of  the  lower  epiphysis 
of  the  tibia.  Trendelenburg  called  particular 
attention  to  this  deviation.  In  the  erect  posi- 
tion the  foot  appears  longer  and  broader,  and 
the  arch  and  sole  flatter.  The  inner  border 
of  the  foot  may  be  in  contact  with  the  floor 
throughout  and  even  convex  inward.  Between 
it  and  the  prominent  internal  malleolus  are 
two  marked  projections,  the  head  of  the  astra- 
galus and  below  and  farther  forward  the  tuber- 
osity of  the  scaphoid.  (Fig-  542.)  The  outer 
border  of  the  foot  is  concave  in  marked  cases 
and  may  be  raised  from  the  ground.  The 
heel  projects  more  prominently  outward  and 
backward.  The  tendo  Achillis  is  usually 
stretched  tightly  and  is  outlined  more  dis- 
tinctly. The  metatarsus  is  often  adducted, 
the  toes  usually  extended,  and  the  great  toe 
sometimes  abducted.  Hallux  valgus  and  in- 
growing toenail  are  frequent  accompaniments. 

The  diagnosis  of  flat-foot  in  a  well-developed  case  is  easy.  To  the 
inexperienced  a  case  seen  before  the  flattening  of  the  sole  was  pro- 
nounced might  present  difficulties,  but  in  such  the  valgus-position 
would  be  conclusive.  Hoffa  has  given  the  name  "bent-foot"  (Knick- 
fuss)  to  this  position.  The  foot  is  still  arched,  but  its  front  portion 
is  strongly  abducted  and  everted.  The  eversion  is  proportional  to  the 
rotation  of  the  astragalus.  The  outward  deviation  of  the  heel  is  par- 
ticularly noticeable  from  behind.  The  "bent-foot"  may  continue  as 
such  through  life,  but  as  a  rule  represents  an  early  stage  of  flat-foot. 

The  discomfort  is  usually  greatest  at  the  beginning,  but  does  not 
always  correspond  to  the  degree  of  deformity.  The  pain  and  fatigue 
are  increased  by  walking  and  especially  by  long  standing;  sometimes 
the  pain  develops  suddenly,  as  after  dancing,  long  walks,  or  protracted 
standing.     Localized  points  of  tenderness  are  found  most  frequently 


Talipes  valgus.    (Kirmisson.) 


CONTRACTURES  ASD  DEFORMITIES  OF  THE  FOOT. 


839 


at  tht'  tuberosity  of  the  scaphoid,  the  head  of  the  astragalus,  and  the 
astragalonavicular  articulation,  corresponding  somevt  hal  to  the  course  of 
the  inferior  calcaneonavicular  ligament;  Less  often  below  and  in  front  of 
the  external  malleolus  at  the  front  of  the  calcaneum  due  to  pressure 
of  thf  edge  of  astragalus — and  on  the  dorsum  at  the  astragalonavicular 
articulation.  Very  frequently  the  entire  heel,  especially  the  under  sur- 
face, is  painful,  less  often  the  metatarsophalangeal  joints,  notably  that 
of  the  great  toe.  The  arch  of  the  foot  may  appear  normal  or  be  dis- 
tinctly flattened.  But  the  excessive  eversion  of  the  foot  is  always 
recognizable. 

In  very  mild  cases  attended  with  only  slight  pain,  motion  of  the  foot  is 
free,  only  forced  passive  inversion  and  eversion  being  painful.  While 
standing  still  the  patient  shifts  from  one  foot  to  the  other,  contracting 
the  extensors,  the  tibialis  anticus,  the  peronei  or  the  calf  muscles  alter- 

Fig.  542. 


Talipes  valgus. 


nately.  If  the  foot  is  very  painful,  it  is  held  firmly  abducted  and  everted 
with  the  muscles  tense;  actively  flexion  and  extension  are  limited  but' 
free  passively  except  in  the  severest  cases.  At  first  the  pain  and  stiffness 
follow  only  after  prolonged  use  of  the  foot,  and  disappear  partially  or 
completely  with  rest;  later  they  become  permanent  and  are  increased 
by  overexertion.  Many  patients  complain  of  painful  cramps  in  the 
feet  or  calves  of  the  leg  at  night,  with  the  stiffness  and  pain  most  marked 
after  resting  or  in  the  morning.  Sometimes  the  ankles  are  swollen 
slightly  and  suggest  an  inflammation  of  the  ioint  or  rheumatism,  and 
are  treated  as  such. 

The  contracture  sometimes  develops  slowly,  sometimes  very  rapidly 
and  is  often  extremely  painful.  Its  etiology  has  been  a  matter  of  great 
dispute.  The  proper  explanation  is  to  be  found  in  the  irritation  pro- 
duced by  displacement  and  excessive  rotation  of  the  joints.     The  liga- 


840 


DISEASES  OF  THE  AXKLE  AND  FOOT. 


merits,  especially  the  inferior  calcaneonavicular  ligament,  and  the  cap- 
sules are  stretched  and  torn,  and  the  periosteum  irritated  at  certain 
points.  As  an  expression  of  this  irritation  we  find  exostoses  in  the  later 
stages,  always  at  the  same  points.  As  this  traumatic  irritation  never 
produces  an  actual  inflammation,  the  term  "inflammatory"  flat-foot 
has  been  properly  discarded.  It  is  painful,  however,  and  thus  causes  a 
reflex  spastic  contracture,  analogous  to  the  contracture  due  to  arthritis. 
From  this  it  can  be  understood  how  only  the  evertors  and  invertors 
are  contracted  in  mild  cases,  and  all  the  muscles  of  the  foot  in  severe 


Fig.  543. 


Fig.  544. 


V,>-5s3-y^' 


An  attitude  thai  simulates  the  flat-foot. 
(See  Fig.  544.)      (Whitman.) 


Fig.  544  compared  with  Fig.  543  illustrates 
the  voluntary  protection  of  the  foot  from  over- 
strain.     (Whitman.) 


cases.  Where  such  fixation  takes  place  suddenly  the  term  acute  flat- 
foot  has  been  applied;  but  if  we  regard  this  fixation  as  a  reflex  contrac- 
ture the  term  talipes  valgus  contractus  is  more  correct.  It  is  important 
to  remember  that  the  contracture  very  often  develops  at  the  beginning  of 
flat-foot,  before  the  arch  has  become  flattened  to  any  extent,  and  that  it 
may  follow  very  suddenly  after  great  fatigue.  This,  together  with  the 
existence  of  painful  stiffness,  points  of  tenderness,  and  a  slight  valgus 
position,  excludes  periostitis,  neuralgia,  or  articular  rheumatism.  In 
older  people  arthritis  deformans  and  gout  may  give  very  similar  symp- 
toms.    Pal  has  recently  called  attention  to  the  fact  that  the  "  meralgia 


CONTRACTURES  AND  DEFORMITIES  of  THE  FOOT. 


841 


paraesthetica "  described  by  Bernhardt — paramnesias  in  the  area  of  the 
external  cutaneous — and  sciatica  are  referable  to  Hat-fool  and  disappear 
after  appropriate  treatment  of  the  latter. 

On  careful  examination  of  the  foot  the  diagnosis  is  usually  simple  at 
the  outset  of  the  affection  unless  accompanied  by  the  effects  of  sprains 
or  fractures  of  the  malleoli.  In  many  instances  the  pain  ceases  and  the 
stiffness  disappears  after  the  bones  and  joints  have  accommodated 
themselves  to  the  changed  position.  But  in  the  majority  of  cases  more 
or  less  stillness  persists,  e version  and  inversion  are  limited,  the  muscles 
may  undergo  nutritive  shortening  so  that  the  tendons  of  the  peronei  are 
displaced  forward  over  the  outer  malleolus;  the  hones  and  joints  are 


Fig.  545. 


Fig.  546. 


Illustrating  the  involuntary-adduction  of 
the  forefoot,  due  to  the  obliquity  of  the 
bearing  surface  of  the  metatarsus  in  the 
proper  attitude  for  walking.    (Whitman.) 


The  improper  attitute  of  outward  rotation,  in 
which  there  is  disuse  of  the  leverage  function. 
(Whitman.) 


deformed  by  destruction  of  the  cartilage  and  growth  of  the  periosteum. 
The  joints  may  be  slightly  movable  or  ankylosed.  The  gait  is  then 
heavy  and  inelastic.  The  amount  of  disturbance  produced  depends 
more  upon  the  degree  of  valgus  than  on  the  flattening  of  the  arch.  If 
the  muscles  are  well  developed  and  the  valgus  slight,  the  disturbance 
is  often  trifling.  Overexertion  may  produce  exacerbations.  Although 
varicose  veins  and  "sweat-foot"  are  frequently  combined  with  flat-foot 
they  usually  precede  it,  the  flat-foot  developing  later  as  the  muscles 
become  weakened  by  the  circulatory  disturbances  caused  by  the  dilated 
veins  (v.  Lesser,  Thomaszewski).  Many  authors  deny  this  connection 
between  the  three  affections. 


842 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


Fig.  547. 


There  is  also  a  form  of  flat-foot  in  which  the  sole  is  convex.  When  the 
deep  muscles  of  the  calf,  the  peronei  and  the  plantar  muscles  have 
become  tired  in  walking,  the  foot  can  be  extended  only  by  the  triceps 
surse  (gastrocnemius  and  soleus);  in  consequence  the  arch  sinks  and 
becomes  convex  downward  in  Chopart's  joint  as  the  weight  is  thrown 
on  the  toes.  Walking  when  the  foot  is  tired  is  therefore  of  unusual 
significance  with  reference  to  this  form  of  flat-foot.     (Nicoladoni.) 

Treatment. — The  treatment  of  congenital  flat-foot  is  the  same  as  that 
of  congenital  talipes  varus,  namely,  massage,  frequent  passive  adduction 
and  inversion  or  forcible  correction  and  permanent  immobilization  in 

inversion  and  extension  in  a  permanent  or 
removable  splint.  The  rhachitic  flat-foot  if 
mild  recovers  spontaneously  like  other  rha- 
chitic curvatures.  The  severer  cases  should 
be  supported  by  means  of  apparatus  and 
shoe-plates,  or  rectified  by  forcible  correction 
and  immobilized  and  later  treated  by  mass- 
age and  apparatus.  General  treatment  of 
the  rhachitis  is  understood. 

In  the  case  of  acquired  static  flat-foot  the 
prophylaxis  is  important.  During  working- 
hours  the  patient  should  walk  with  the  toes 
forward  or,  better,  turned  in,  and  while 
standing  turn  the  toes  slightly  inward,  and  if 
possible  lift  himself  at  intervals  upon  the 
toes  to  strengthen  the  muscles  and  increase 
the  circulation.  Long  standing  should  be 
avoided  and  the  feet  rested  as  much  as  pos- 
sible. Gymnastic  exercises  combined  with 
massage  are  the  most  valuable  means  of  pre- 
venting and  curing  flat-foot  in  the  first  stages. 
Massage  should  be  directed  chiefly  to  the 
muscles  of  the  sole  and  leg,  especially  the 
tibialis  posticus  and  other  calf  muscles.  The 
gymnastic  exercises  consist  in  rising  upon 
the  toes  with  the  feet  turned  in;  standing 
upon  the  heel  with  the  feet  turned  in  strongly; 
squatting  with  the  weight  on  the  heel  and 
The  proper  relation  of  the  sole  to  the  foot  turned  in ;  rotating  the  foot  inward 
the  shape  of  the  foot,  a,  outline  of    wnije  sitting  with  the  knee  extended,  with 

sole;   B,  outline  of  foo^;  C,  imprint  .         .  °  „       ,  , 

of  foot.    (Whitman.)  and  without  counterpressure  of    the  physi- 

cian's hand  ;  in  fact,  any  exercise  which 
tends  to  strengthen  the  invertors. 

Among  more  intelligent  patients  these  measures  often  give  grateful 
results.  If  possible,  an  injurious  occupation  should  be  exchanged  for 
one  less  so  or  even  beneficial  in  requiring  toe-work. 

The  shoe  is  very  important;  it  should  not  be  loose  nor  tight  (hallux 
valgus!)  and  should  allow  free  play  of  the  toes.     Lorenz,  H.  v.  Meyer, 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT. 


843 


and  others  recommend  high  heels.  With  most  orthopaedists  and  sur- 
geons we  believe  this  is  wrong,  and  recommend  a  low,  broad  heel. 
Nor  can  we  agree  with  Ellis  in  doing  away  with  the  heel  entirely  and 
raising  the  front  of  the  foot.     To  support  the  arch  the  shoe  is  raised  on 


Fig.  548. 


Fig.  549. 


Fig.  550 


Flat-foot  shoe.     (After  Miller 
and  Thomas.) 


Beely's  flat-foot  shoe.     (Hoffa.) 


the  inner  side  (Fig.  548)  or  a  plate  is  worn  in  the  shoe,  the  latter  being 
generally  preferred.  The  two  are  also  combined.  Beely  extends  the 
heel  forward  and  inward.     (Figs.  549,  550.)     Lorenz  raises  the  entire 


Fig.  551. 


Hoffa's  foot-brace. 


inner  border  of  the  foot,  the  heel  of  the  shoe  extending  forward  to 
the  calcaneocuboid  articulation,  with  a  depression  inside  of  the  shoe  at 
the  outer  side  for  the  calcaneum.  Meyer  makes  this  depression  at  the 
inner  side  of  the  heel  so  as  to  force  the  calcaneum  inward.     Plates 


844 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


made  of  felt,  cork,  leather,  rubber,  or  other  such  material  are  ineffectual; 
they  force  the  foot  outward  without  supporting  it.  A  plate  should 
support  the  entire  arch,  and  should  therefore  have  the  normal  arch  of 
the  sole,  extending  from  the  heel  to  the  ball  of  the  foot  and  from  one 
side  to  the  other.  (Figs.  551 ,  552.)  The  outer  edge  should  be  bent  up 
slightly  to  prevent  the  foot  from  slipping  outward.  If  properly  shaped 
and  fastened  in  the  shoe,  it  produces  no  discomfort.     L.  Heidenhain 


Fig.  553. 


A,  the  astragalonavicular  joint.      The  internal  flange  of  the  brace  should  rise  well  above  all  the 
prominent  bones  to  a  point  about  half  an  inch  below  the  malleolus.    (Whitman.) 


Fig.  554. 


Fig.  555. 


B,  the  calcaneocuboid  junction.  The  external 
flange  extends  from  the  centre  of  the  heel  to  a 
point  just  behind  the  base  of  the  fifth  metatarsal 
bone.     (Whitman.) 


C,  the  great  toe-joint;  D,  the  centre 
of  the  heel.     (Whitman.) 


makes  a  large  plate  of  the  size  of  the  foot  and  shaped  after  a  plaster 
model.  The  suggestions  of  the  American  orthopaedists  (Whitman 
(Figs.  553-555),  Dane,  Sydney,  Roberts)  are  particularly  valuable. 
The  best  material  is  sheet  steel  (Xo.  18-20  gauge)  or  aluminnm-bronze; 
celluloid  and  durana  have  also  been  recommended  recently.  The 
plate  is  moulded  upon  a  wax  or  plaster  impression  of  the  arch  of  the 


CONTRACTURES  AM)   DEFORMITIES  OF  THE  FOOT.         £45 

foot  shaped  up  somewhat  to  increase  the  arch.  In  very  severe  a 
this  increase  has  to  be  effected  gradually  through  several  weeks  before 
the  normal  arch  is  attained.  To  obtain  the  form  of  the  tool  when 
inverted,  arched  and  weighted,  Lange  binds  a  cotton  pad,  corresponding 
to  the  arch,  on  the  affected  Fool  and  over  this  a  plaster  splint  to  above 
tin-  malleoli.  The  patient  then  stands  with  the  foot  on  an  inclined 
surface,  having  a  strip  to  prevent  the  foot  from  slipping  sideways,  till  the 
plaster  hardens.  It  is  then  cut  off  and  a  east  made  of  it.  over  which  the 
plate  is  moulded.  The  plate  should  be  fastened  in  the  shoe.  Marci- 
nowski  recommends  that  a  side  leg-brace  be  attached  to  the  plate  in 
severe  cases  to  prevent  the  plate  from  slipping  and  thus  possibly 
twisting  the  foot  outward. 

A  well-fitting  plate  relieves  the  discomfort  rapidly  and  in  time  restores 
the  arch  of  the  foot.  It  has  to  be  worn  permanently  unless  a  cure  is 
possible  by  means  of  massage  and  gymnastic  exercises.  Recently 
operations  have  been  combined  with  this  treatment:  Hoffa  assumes 
that  the  tendon  of  the  tibialis  posticus  is  stretched,  and  so  shortens  it; 
Lange,  Franke  and  others  have  performed  the  same  operation  success- 
fully. Nicoladoni  splits  the  tendo  Achillis  and  sutures  one-half  of  it  to 
the  tendon  of  the  tibialis  posticus.  E.  Miiller  has  separated  the  tendon 
of  the  tibialis  anticus  from  its  insertion  and  sutured  it  with  wire  to  the 
scaphoid  through  a  tunnel  cut  in  the  bone.  A  plate  is  not  effectual 
unless  the  bones  are  movable,  so  that  the  foot  should  be  mobilized 
forcibly,  if  the  bones  are  fixed,  before  adjusting  the  plate. 

The  spastic  contracture  in  acute  contracted  flat-foot  is  relieved  by 
hot  compresses,  rest,  and  massage.  Severe  contracture  is  overcome 
more  rapidly  by  immobilizing  the  foot  in  maximal  inversion  under  local 
cocaine  or  general  anaesthesia.  In  from  four  to  ten  minutes  after 
injecting  grain  |  to  f  (0.02-0.05  gm.)  of  cocaine  into  the  astragalo- 
navicular  joint  the  foot  can  usually  be  moved  actively  and  passively 
without  pain.  The  plaster-splint  is  worn  for  three  weeks.  In  older 
cases  with  slirinkage  of  the  soft  parts  and  deformation  of  the  bones  and 
joints,  forcible  correction  should  be  carried  out  under  anaesthesia.  With 
the  foot  held  extended  it  is  first  adducted;  then  it  is  moved  in  all  direc- 
tions and  again  adducted  and  inverted  stronglv,  then  flexed  while  in 
this  position  and  moved  again  in  all  directions.  If  the  tendo  Achillis 
is  short  and  tense  and  interferes  with  the  manipulation,  it  should  be 
divided.  In  spite  of  the  breaking  up  of  adhesions  and  necessary  tearing 
of  the  soft  parts  there  is  little  reaction.  The  patient  can  go  about  on 
crutches  in  the  plaster-splint  after  a  few  days.  In  three  weeks  the  splint 
is  removed,  the  foot  massaged  and  moved,  a  previously  made  plate  is 
worn  in  the  shoe,  and  gymnastic  exercises  performed  systematically; 
it  may  be  necessary  to  repeat  the  manipulation  in  order  to  complete  the 
correction. 

For  severe  and  old  non-rectifiable  cases  operations  have  been  pro- 
posed aiming  to  restore  the  arch  by  removing  portions  of  the  bones  on 
the  inner  side  of  the  foot.  Golding  Bird  removes  the  scaphoid,  Vogt  the 
astragalus.     Ogston  resects  the  head  of  the  astragalus  and  the  articular 


g46  DISEASES  OF  THE  ANKLE  AND  FOOT. 

surface  of  the  scaphoid,  and  sutures  the  two  bones  together  to  obtain 
bony  union;  the  operation  has  been  repeatedly  successful.  Stokes 
resects  a  wedge  from  the  head  and  neck  of  the  astragalus.  Schwartz 
chisels  a  wedge  from  the  inner  side  of  the  foot  without  regard  to  the 
joints,  chiefly  from  the  astragalus  and  scaphoid.  Excision  of  a  wedge 
is  the  most  practical  procedure;  the  bones  are  sutured  with  wire.  To 
avoid  the  stiffening  of  the  arch  produced  by  the  above  operations  Tren- 
delenburg and  Hahn  prefer  to  divide  the  tibia  and  fibula  just  above  the 
ankle-joint  through  an  inner  and  outer  incision,  overcorrect  the  deformity 
and  apply  a  plaster-splint,  v.  Eiselsberg  divides  the  calcaneum  from 
before  and  below  upward  and  backward  and  shifts  the  posterior  frag- 
ment downward  and  forward  to  increase  the  angle  formed  by  the 
calcaneum  with  the  ground,  and  if  this  is  not  sufficient  removes  a  wedge 
from  the  bone  with  base  below.  If  the  calcaneum  is  everted,  the 
posterior  fragment  is  shifted  inward  at  the  same  time.  The  results  are 
favorably  reported  by  some  authors,  but  unfavorably  by  Marcinowski 
in  three  cases  in  v.  Mikulicz'  clinic. 

Tendon  transplantation  has  been  tried  repeatedly  with  success  in 
paralytic  flat-foot.  The  tendon  of  the  paralyzed  tibialis  anticus  has 
been  sutured  to  the  extensor  hallucis,  peroneus  longus  or  tertius,  etc.;  the 
tendons  have  also  been  shifted  subperiosteally,  as  proposed  by  Lange, 
for  example,  the  tendon  of  the  peroneus  longus  carried  behind  the  tendo 
Achillis  to  the  inner  border  of  the  foot  and  sutured  to  the  calcaneum. 
(Drobnik,  Vulpius;  compare  the  operations  in  Talipes  Calcaneus  and 
Calcaneo valgus.)  These  procedures  were  usually  beneficial  and  are 
worthy  of  trial.     (Nicoladoni.) 

Arthrodesis,  performed  many  times  on  the  tibiotarsal  joint,  to  be 
effectual  in  these  cases  generally  has  to  include  also  the  calcaneo- 
astragaloid  or  the  mediotarsal  joint,  according  to  which  shows  the 
greatest  abnormal  mobility.  For  the  ankle-joint  Samter's  incision  is 
preferable;  a  posterior  longitudinal  incision  with  division  of  the  tendo 
Achillis  and  subsequent  suture.  The  tibiotarsal  and  mediotarsal  joints 
are  best  reached  through  an  anterior  curved  incision. 

Talipes  Calcaneus. — Talipes  calcaneus  is  characterized  by  marked 
downward  projection  of  the  heel.  According  to  Nicoladoni,  we  dis- 
tinguish two  main  types:  1.  Pes  for  talipes)  calcaneus  sursum  nexus, 
due  to  pronounced  flexion  of  the  foot.  It  may  be  congenital,  or  acquired 
(a)  through  paralysis;  (h)  through  pathological  processes  in  or  about 
the  ankle-joint.  2.  Pes  (or  talipes)  calcaneus  sensu  strictiori,  due 
purely  to  the  low  position  of  the  heel.     It  is  always  acquired. 

In  congenital  talipes  calcaneus  sursum  flexus  dorsal  flexion  is  com- 
monly very  pronounced;  the  muscles  of  the  leg  and  foot  are  normal,  the 
movements  of  the  limb  are  prompt.  (Fig.  556.)  Every  effort  to  extend 
the  foot  is  prevented  by  the  visible  tension  of  the  tendons  on  the  dorsum. 
Like  talipes  varus  and  valgus,  the  deformity  is  unquestionably  due  to 
intrauterine  pressure  resulting  from  faulty  position  of  the  foot  and  lack 
of  space.  Very  often  the  foot  is  also  everted  and  abducted,  talipes 
calcaneovalgus;  sometimes  the  valgus,  sometimes  the  calcaneus  position 


VoyrilACTl'llES  AM)  DEFORMITIES  OF  THE  FOOT. 


847 


predominating.  The  sole  is  usually  flattened.  The  distinction  made 
between  talipes  valgus  with  flexion  and  talipes  calcaneus  is  therefore 
often  arbitrary.  The  anatomical  changes  in  the  two  conditions  are 
very  similar.     (Messner,  Kustner,  see  page  829.) 

The  paralytic  form  usually  results  secondarily  from  the  weighting  of 
the  foot  after  paralysis  of  the  plantar  flexors,  rarely  primarily  from  active 
contraction  of  the  dorsal  flexors.  The  mode  of  development,  according 
to  v.  Volkmann,  is  that  the  foot  is  flexed  by  the  body-weight,  if  used 
in  walking,  as  it  is  no  longer  held  by  the  paralyzed  calf  muscles,  and 
usually  becomes  more  or  less  everted  and  abducted  at  the  same  time. 
Fig.  557.)  If  the  patient  takes  short  steps  and  plants  the  entire  foot 
and  not  the  heel  first,  then  only  the  weight  acts,  and  flexion  is  limited 


Fig.  556. 


Fig.  557. 


Congenital  talipes  calcaneus.   (Xicoladoni.) 


^ 


Paralytic  talipes  calcaneus.     (Hoffa.) 


by  the  check  action  of  the  ligaments,  etc.  This  limitation  diminishes, 
however,  as  the  shape  of  the  bones  gradually  changes  and  the  ligaments 
and  tendons  become  stretched  and  shifted;  the  foot  is  then  flexed  strongly 
at  each  step.  If  the  patient  takes  long  steps,  the  back  of  the  heel  strikes 
the  ground  and  the  calcaneum  is  twisted  forward.  This  happens  espe- 
cially if  the  knee  is  hyperextended  in  swinging  the  leg  forward,  as  it 
occurs,  for  example,  with  paralysis  of  the  quadriceps.  The  calcaneum 
may  thus  become  bent  forward.  If  the  dorsal  flexors  are  also  paralyzed 
or  weakened,  the  front  part  of  the  foot  is  apt  to  be  bent  down  gradually 
by  its  own  weight.     The  foot  thus  becomes  a  paralytic  talipes  cavus. 

Flexion  is  always  retained  in  the  ankle-joint,  however,  even  if  talipes 
cavus  develops.  In  the  talipes  calcaneus  sensu  strictiori  of  Xicoladoni 
the  heel  points  directly  downward,  the  dorsum  of  the  foot  is  at  an  angle 


848 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


of  slightly  more  than  90  degrees  to  the  leg,  the  sole  is  highly  arched,, 
and  the  patient  walks  upon  the  heel  and  the  ball  of  the  great  and 
little  toe.  The  ankle-joint  is  not  fixed  in  extreme  flexion,  but  can  still 
be  flexed  slightly.  Yet  according  to  Nicoladoni  any  movement  of 
flexion  is  not  and  never  was  possible  in  the  ankle-joint.  The  foot  is 
bent  upon  itself  at  two  points  in  the  sole:  at  the  tarsometatarsal 
joints  and  beneath  the  front  part  of  the  calcaneum.  The  posterior 
process  of  the  calcaneum  becomes  an  inferior  process,  so  that  the  heel 
is  less  prominent  than  usual.  (Fig.  558.)  According  to  Nicoladoni, 
the  condition  is  due  to  paralysis  of  the  muscles  of  the  calf,  the  peronei, 
dorsal  flexors,  and  plantar  muscles  being  intact.  Every  time  the  foot 
is  raised  and  lowered  the  calcaneum  is  pulled  upon  by  the  plantar 
muscles  until  in  the  course  of  years  the  foot  and  its  bones  resemble  in 
form  the  foot  of  a  Chinese  woman. 

Fig.  558 


Talipes  (pes)  calcaneus  sensu  strictiori.     (v.  Bruns.) 


Treatment. — The  congenital  form  merely  requires  passive  move- 
ments, energetic  manipulation,  and  massage.  Stubborn  cases  demand 
correction  under  amesthesia  and  immobilization.  Very  severe  or  old 
cases  are  overcome  more  rapidly  by  dividing  the  dorsal  tendons. 

In  the  paralytic  cases,  to  prevent  the  excessive  flexion,  v.  Volkmann 
replaces  the  action  of  the  paralyzed  muscles  by  strong  elastic  bands. 
(Fig.  559.)  Judson  applies  an  outer  brace  along  the  leg  with  an  adjust- 
able, hinged  foot-plate  or  sheath  permitting  full  extension,  but  flexion 
only  to  a  right  angle.  Hoffa's  apparatus  (Fig.  560)  consists  of  a  Hessing 
laced  leather  foot-sheath  fastened  to  a  foot-plate  which  is  hinged  at  the 
ankle  to  two  lateral  braces  extending  to  and  fastened  below  the  knee  by 
a  strap;  the  eversion  and  flexion  of  the  foot  are  overcome  by  means 
of  appropriately  attached  rubber  bands.  Such  apparatus  may  also  be 
used  for  the  second  type  of  talipes  calcaneus.  The  treatment  of  the 
severe  forms  combined  with  talipes  cavus  will  be  described  under  the 
latter. 


CONTRACTURES  AND  DEFORMITIES  OF  THE  FOOT.        849 

In  the  paralytic  cases  Willet  shortens  the  tendo  Achillis.  The  opera- 
tion has  been  performed  by  others  with  varying  results.  Among  28 
cases,  Gibney  obtained  17  complete  results — even  in  the  absence  of 
primary  union;  8  were  satisfactory,  and  3  were  not  improved.     The 

result  apparently  depends  less  upon  the  strength  of  the  sutured  tendon 
than  the  condition  of  the  muscles;  if  the  gastrocnemius  and  soleus  are 
completely  paralyzed  and  atrophied,  they  are  more  liable  to  stretch 
than  if  only  partially  paralyzed.  Hence  the  shortening  of  the  tendons 
is  more  likely  to  be  successful  if  the  muscles  are  only  partially  atrophic. 
Partial  degeneration  of  the  calf  muscles  is  apparently  the  more  frequent 
occurrence.    The  permanency  of  the  results  still  has  to  be  proved. 


Fig.  559. 


Fig.  560 


Volkmann's  apparatus  for  talipes  calcaneus. 
fHoffa.) 


Hoffa's   apparatus  for  talipes  calcaneus. 


Tendon  transplantation,  as  employed  first  by  Xicoladoni  for  paralysis 
of  the  calf  muscles,  apparently  gives  the  best  results  if  the  muscles  are 
only  partially  paralyzed  and  the  tendons  can  be  shortened  at  the  time  of 
operation.  If  the  paralysis  is  extensive  and  the  foot  very  loose,  arthro- 
desis of  the  tibiotarsal  joint  is  preferable,  and  also  of  the  calcaneo-astrag- 
aloid  or  mediotarsal  if  necessary.  It  is  customary  to  fix  the  foot  at  a 
right  angle  to  the  leg.  In  cases  where  the  leg  was  much  shortened  it 
has  been  lengthened  by  the  Wladimiroff-Mikulicz  resection  method. 
HofTa  obtained  a  very  good  result  in  a  severe  case  of  talipes  calcaneus 
by  dividing  the  tuberosity  of  the  calcaneum  obliquely,  shifting  it  upward 
Vol.  III.— 54 


850 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


and  backward,  and  shortening  the  tendo  Achillis.     Laurent  obtained 
an  excellent  result  by  resecting  the  scaphoid  and  cuboid. 

Talipes  Cavus  (Hollow  or  contracted  foot,  pes  excavatus,  pes  arcu- 
atus,  talipes  percavus,  talipes  plantaris,  non-deforming  club-foot). — 
The  term  talipes  cavus  is  applied  to  abnormal  arching  of  the  foot. 
The  arching  in  pes  calcaneus  sensu  strictiori  is  present  from  the  first, 

Fig.  561. 


Fig.  562. 


Beely's  correction  apparatus  for  hollow-foot.     (Hoffa.) 

and  is  a  genuine  talipes  cavus.  Associated  with  talipes  equinus  or 
equinovarus  and  congenital  paralytic  talipes  calcaneus  it  is  usually 
not  an  essential  but  secondary  condition. 

The  pied  creux  of  the  French  (Duchenne;  Klauenhohlfuss)  is  a 
variety  of  paralytic  talipes  cavus  due  to  paralysis  of  the  interossei, 

lumbricales,  and  muscles  inserted  in 
the  sesamoid  bones  of  the  great  toe 
(flexor  brevis  and  adductor  hallucis). 
The  toes  then  assume  a  peculiar  claw 
attitude  and  the  metatarsus  becomes 
depressed.  On  first  thought  it  suggests 
talipes  equinus  but  for  the  fact  that 
the  tibiotarsal  joint  is  not  extended, 
but  on  the  contrary  becomes  increas- 
ingly flexed  the  more  the  metatarsals 
are  depressed  and  the  arch  of  the  sole 
is  raised. 

Other  non-paralytic  varieties  are  also 
seen.  Some  are  congenital  and  pos- 
sibly due  to  intrauterine  pressure.  According  to  Hoffa,  they  are  also 
hereditary.  Short  shoes  may  produce  hollow  feet  in  children,  analo- 
gous to  the  feet  of  Chinese  women. 

In  severe  cases  of  hollow-foot  there  may  be  considerable  discomfort 
from  tarsalgia  and  painful  callosities.  In  children  the  deformity  may 
be  overcome  by  manual  correction  or  with  the  aid  of  Heusner's  appa- 


Beely's  correction  apparatus  for  hollow- 
foot.      (Hoffa.) 


CONTRACTURES  AND  DEFORMITIES  OF  THE  TOES.        851 

ratus  (Ringhebels).  If  necessary,  the  superficial  plantar  fascia  can  t>e 
divided  siibcutaneously  or  openly  and  the  foot  immobilized,  after  cor- 
rection on  a  straight  splint  or  in  plaster.  Of  the  various  apparatus 
proposed  for  gradual  or  forcible  correction,  Beely's  is  the  most  practical. 
After  the  position  is  rectified  (Fig.  561)  it  is  maintained  at  night  in  a 
frame  of  similar  form  by  means  of  elastic  hands.      (  Fig.  562.) 


CONTRACTURES  AND  DEFORMITIES  OF   THE  TOES. 

Hallux  Valgus. — The  most  important  of  the  deformities  of  the  toes  is 
the  abduction  of  the  hallux  in  the  metatarsophalangeal  joint.  As  a 
rule  it  is  undoubtedly  due  to  purely  mechanical  causes,  namely,  improper 
shoes.     In  children  who  have  never  worn  stiff  shoes  or  in  individuals 


Fig.  563. 


Fig.  564. 


Fig.  565. 


Proper  shapes. 


Improper  shape.    (H.  v.  Meyer.) 


who  have  always  gone  barefooted  the  great  toe  is  in  line  with  or  turns 
slightly  inward  from  the  inner  border  of  the  foot.  This  is  the  normal 
position.  In  most  people  the  great  toe,  contrary  to  the  aesthetic  require-' 
ments  of  the  ancient  Greeks,  is  the  longest.  Shoes  which  are  too 
narrow  or  too  pointed  crowd  the  great  toe  toward  the  middle  line  of  the 
foot.  A  shoe  may  be  pointed,  but  the  point  should  correspond  to  the 
great  toe  and  give  free  play  to  all  the  toes.  (Figs.  563  to  569.)  The 
higher  the  heel,  the  more  the  foot  is  pushed  forward  and  the  toes  crowded 
together.  Hallux  valgus  is  therefore  very  rare  in  children,  and  more 
frequent  among  the  wealthier  classes  in  cities,  especially  among  women 
who  wear  narrow-pointed  shoes  from  vanity,  than  among  country  people. 
The  anatomical  changes  were  first  studied  by  Broca,  more  recently 
by  Delarochaulion,  Payr,  Ajevoli,  Heubach,  and  others.  In  marked 
cases  the  phalanx  articulates  with  only  the  outer  half  of  the  articular 
surface  of  the  head  of  the  metatarsal;  the  latter  is  thickened  outward 


852 


DISEASES  OF  THE  ANKLE  AND  FOOT. 


and  its  cartilaginous  surface  extended.  The  inner  half  of  the  articular 
surface  is  often  separated  from  the  outer  half  by  a  deep  groove  and  its 
cartilage  is  defective  or  absent.  The  exostosis  described  by  v.  Volkmann 
is  a  growth  of  the  tuberosity  behind  the  joint,  due  to  the  irritation.  The 
sesamoid  bones  are  both  dislocated  outward.  The  metatarsal  deviates 
inward  in  severe  cases  so  that  the  foot  is  abnormally  wide.     It  may  be 


Fir,.  566. 


Fm.   567. 


Normal  feet. 

Fig.  568 


Proper  soles  for  normal  feet. 

Fig.  569- 


Shoemaker's  feet. 


(Whitman.) 


Shoemaker's  snles. 


also  rotated  on  its  long  axis  with  the  phalanx  till  the  upper  surface  faces 
inward.  The  articular  surface  of  the  phalanx  is  diagonal  to  the  long 
axis.  The  outward  displacement  of  the  flexor  and  extensor  tendons 
maintain  or  increase  the  deformity.  After  the  condition  has  existed  for 
some  time  the  synovialis  becomes  thickened  and  covered  with  villous 
growths,  the  cartilage  and  bone  are  partly  eroded,  partly  increased, 


CONTRACTURES  AM)  DEFORMITIES  OF  Till-!  Tolls. 


853 


much  the  same  as  in  arthritis  deformans.     The  latter  has  therefore 
been  improperly  regarded  as  the  cause  of  the  valgus  position. 

Fig.  570. 


Hallux  valgus.     (v.  liruus.) 


Fig.  571. 


Fir..  572. 


Hallux  valgus.     (Hoffa.) 


The  toe  may  be  abducted  70  or  80  degrees  and  lie  above  or  beneath 
the  second  toe.     (Figs.  571  and  572.)     A  callosity,  clavns,  or  even  per- 


854  DISEASES  OF  THE  ANKLE  AND  FOOT. 

niones,  frequently  develops  at  the  inner  side  of  the  head  of  the  first  meta- 
tarsal, having  beneath  it  a  single  or  multilocular  bursa,  often  communi- 
cating with  the  joint.  The  pain  produced  by  the  corn  and  bursa  is 
increased  if  the  latter  becomes  inflamed  and  suppurates.  If  the  pus 
perforates  outward,  a  fistula  is  left.  As  long  as  the  latter  remains  open 
the  pain  may  be  moderate,  but  as  soon  as  it  becomes  closed  and  retention 
occurs  the  pain  becomes  intense  again.  The  pus  may  perforate  into 
the  joint,  if  there  is  already  no  communication,  and  cause  suppuration 
of  the  joint.  Lymphangitis  and  cellulitis  occasionally  follow  and  make 
the  affection  serious.  Even  without  these  complications  the  pain  due  to 
the  arthritis  deformans  and  the  pressure  of  the  shoe  may  be  very  severe. 
As  v.  Volkmann  says,  the  patient's  struggles  with  his  shoemaker  bring 
him  no  relief.  Hammer-toe  of  the  second  toe  and  ingrowing  toenail 
are  frequent  sequela?,  the  latter  most  frequently  on  the  outer  side  of  the 
great  toe  where  it  presses  against  the  second  toe,  less  often  on  the  inner 
side.  The  gait  is  usually  heavy  and  shuffling  in  marked  cases  as  the 
foot  cannot  be  lifted  so  as  to  clear  the  ground.  This  is  true  even  if 
the  arch  of  the  foot  is  unaffected,  and  even  more  so  if  flat-foot 
develops,  which  happens  very  often  with  pronounced  hallux  valgus. 

Treatment. — The  first  principle  of  treatment  in  all  cases  is  the  wear- 
ing of  proper  shoes  with  low  heels  and  plenty  of  room.  For  gradual 
correction  of  the  deformity  small  splints  with  strips  of  adhesive  plaster 
or  rubber  bands,  and  a  number  of  apparatus,  have  been  recommended. 
The  most  comfortable  of  these  is  a  padded  steel  spring  fastened  on  the 
inner  side  of  the  toe  with  adhesive  plaster,  to  which  the  toe  is  bandaged. 
All  splints  and  apparatus  of  this  sort  are  very  uncomfortable,  are  apt  to 
cause  pressure  in  the  shoe,  and  act  slowly.  It  is  simpler  and  more 
effectual  to  correct  the  deformity  forcibly  and  apply  a  plaster-splint. 
Even  this  does  not  succeed  in  severe  cases  or  acts  too  slowly,  so  that 
various  operations  have  been  recommended.  [Whitman  suggests 
Holden's  toepost,  recommended  by  Walsham  and  Hughes,  consisting 
of  a  thin  metal  upright  plate  fastened  in  the  shoe,  so  as  to  separate 
the  first  and  second  toes  and  hold  the  former  in  an  improved  posi- 
tion. Also  Sampson's  tin  toepost  fastened  to  a  cardboard  inner  sole. 
(Figs.  573  to  57(3.)]  The  oldest  operative  method  is  resection  of  the 
joint  and  excision  of  the  sesamoid  bones  (Hamilton,  Rose);  it  has  been 
advocated  again  recently  by  Heubach.  An  incision  along  the  inner  side 
of  the  joint  makes  it  possible  to  excise  the  corn  and  bursa  at  the  same 
time,  but  it  has  the  disadvantage  of  leaving  a  scar  where  it  is  most 
exposed  to  pressure.  This  can  be  obviated  by  making  the  incision 
between  the  first  and  second  toes.  Riedel  asserts  that  the  results  of 
resection  are  good  only  if  flat-foot  exists,  for  otherwise  the  removal  of 
the  head  of  the  metatarsal,  one  of  the  chief  supports  of  the  foot,  is  fol- 
lowed by  very  great  disability.  The  head  should  therefore  be  pre- 
served and  merely  smoothed  off,  the  exostoses  chiselled  off,  and  the  base 
of  the  phalanx  resected;  or  with  Schede,  one  may  merely  excise  the 
bursa  and  remove  the  part  of  the  head  not  in  contact  with  the  phalanx. 
Any  persisting  valgus  position  is  supposed  not  to  produce  any  further 


CONTRACTURES   AND  DEFORMITIES  OF  THE  TOES. 


855 


disturbance.  The  best  method  is  thai  of  Barker  and  Reverdin,  recently 
recommended  by  Riedel,  namely,  removal  of  the  exostosis  and  of  a 
wedge   from  the  metatarsal    just   above   the  head.      In   some  cases  the 

exostosis  liinv  be  left. 


Fig.  573. 
E 

c 

H 

r' 

Making  the  pattern  fur  a  toepost.  A  heavy  piece  of  paper  folded  once  along  the  line  A  B. 
A  D  E  and  B  C  F are  cut  away,  leaving  the  tongue  A  D  C  B.  A  D  should  equal  the  depth  of  the 
shoe  at  that  point,  and  A  B  should  be  as  wide  as  the  length  of  the  slit  in  the  cardboard  inner 
sole.  The  tongue  is  inserted  in  the  slit,  and  the  bases  folded  back  and  cut  away  to  conform 
to  the  front  of  the  inner  sole.  When  removed  and  straightened  out  this  forms  the  pattern  in 
Fig.  574. 

Fig.  574. 
E  E 


D 


D 


H 


--nC 


F  E 

Pattern  of  paper  from  which  the  tin  is  cut.     The  edges  D  D  and  C  C  are  to  be  turned  in. 
folded  along  the  dotted  lines  A  B—D  C  and  D  C  forming  the  toepost  in  Fig.  575. 


Tin  is 


Fig.  575. 


Shows  the  toepost  ready  to  be  inserted  into  the  cardboard  inner  sole.  Rough  points  on  the 
upper  and  under  surfaces  of  the  base,  which  are  made  by  punching  holes  with  an  awl,  hold  the 
toepost  to  both  the  inner  sole  of  the  shoe  and  the  cardboard  inner  sole. 

Fig.  576. 


Cardboard  inner  sole  with  toepost  and  foot  adductor  attached.     (Sampson.) 


Hallux  Varus. — Adduction  of  the  great  toe  is  very  rare,  and  is  seen 
almost  exclusively  in  connection  with  other  congenital  or  acquired 
deformities  of  the  foot.  The  toe  may  be  bound  in  position.  Operation 
is  almost  never  necessary. 


856  DISEASES  OF  THE  AXKLE  AND  FOOT. 

Lateral  Contractures. — Lateral  contractures  of  the  other  toes  are 
rare,  and  are  seen  chiefly  in  the  little  toe,  which  becomes  adducted  from 
pressure  of  the  shoe.  The  other  toes  may  overlap  from  wearing  improper 
shoes,  cause  pressure  ulcers  and  ingrowing  toenails,  and  be  very  trouble- 
some. They  may  be  straightened  forcibly  and  bandaged  in  place,  but 
are  often  more  willingly  sacrificed. 

Flexion  and  Extension  Contractures.— Flexion  and  extension  con- 
tractures of  the  toes  are  accompaniments  and  sequela?  of  the  various 
contractures  of  the  foot,  talipes  valgus,  equinus,  varus,  etc.  Pure 
flexion  contractures  of  the  metatarsophalangeal  and  interphalangeal 
joints  are  mostly  the  result  of  paralyses  (for  example,  severe  talipes 
equinus),  although  also  said  to  be  congenital.  The  most  common  form 
of  contracture  is  that  in  which  the  first  phalanx  is  extended  and  the 
others  flexed.  Occasionally  all  the  toes  are  affected  and  the  sole  of  the 
foot  is  arched  abnormally  above  the  metatarsophalangeal  joints  as  in 
hollow-foot.  This  is  seen  as  the  result  of  infantile  spinal  paralysis  or 
the  wearing  of  short  shoes,  especially  with  high  heels,  while  the  foot  and 
toes  are  growing.  The  heads  of  the  metatarsals  project  downward 
abnormally  and  painful  callosities  develop  under  them.  Severe  neu- 
ralgic pains  affecting  the  metatarsus  or  even  the  tarsus  may  occur  in 
people  who  have  to  stand  or  walk  a  great  deal. 

Hammer-toe. — Hammer-toe,  a  flexion  contracture  of  single  toes,  is 
more  common.  The  first  phalanx  is  extended,  the  second  flexed,  and 
the  third  either  flexed  or  extended.  It  occurs  most  frequently  in  the 
second  toe.  It  is  rarely  congenital,  as  some  authors  maintain,  but 
usually  due  to  improper  shoes.  It  is  more  often  caused  by  lateral 
deviation  of  the  great  toe  from  wearing  narrow  shoes,  than  by  the  press- 
ure of  shoes  which  are  too  short.  In  hallux  valgus  the  first  toe  gen- 
erally lies  over  the  second  and  presses  it  downward  and  backward;  if 
it  lies  under  the  second  toe,  the  latter  is  merely  extended  in  the  metatarso- 
phalangeal joint.  Sometimes  the  second  and  fourth  are  hammer-toes  and 
lie  over  the  others.  As  the  toes  thus  deviate  laterally  at  the  same  time 
they  are  arranged  in  two  rows  (chevauchement  des  orteils).  This  is 
positive  evidence  of  pressure. 

Occasionally  the  flexion  contracture  is  limited  to  the  great  toe. 
Usually  the  interphalangeal  joint  is  then  flexed;  but  it  may  be  hyper- 
extended,  while  the  flexion  contracture  is  in  the  metatarsophalangeal 
joint. 

The  occasional  coexistence  of  hammer-toe  and  flat-foot  is  differently 
explained  by  various  authors,  some  assuming  the  former,  others  the 
latter  as  primary.  We  have  seen  a  few  cases  in  which  the  hammer-toe 
was  secondary.  Hofmann  calls  this  the  club-toe  position  because  the 
toes  are  adducted  and  flexed;  it  is  most  pronounced  in  the  great  toe, 
less  so  in  the  others.  The  front  part  of  the  foot  is  inverted  and  the 
arch  flattened  (club-toe  flat-foot).  The  deformity  is  at  first  a  temporary 
attitude  of  relief  in  painful  conditions  of  the  leg  (flat-foot,  affections 
of  the  knee),  but  later  becomes  fixed.  The  treatment  is  that  of  the 
underlying  disease, 


CONTRACTURES  AND  DEFORMITIES  OF  THE  TOES.        857 

Slight  flexion  contractures  are  not  noticed  by  the  patient.     In  marked 

cases  painful  corns  form  on  the  sole  under  the  head  of  the  metatarsal,  on 
die  upper  surface  of  the  toe  over  the  first  interphalangeal  joint,  and 
often  on  the  end  of  the  toe  close  to  the  nail.  A  painful  bursa  often 
develops  under  the  corn  on  the  dorsum  of  the  toe,  suppurates,  perforates 

outward  and  also  communicates  with  the  joint.  The  pressure  of  the 
shoe  may  be  unbearable. 

Treatment.  Sandals  with  elastic  loops  have  been  recommended  for 
flexion  contracture  of  all  the  toes.  Konig  divides  the  flexor  tendon  of 
the  great  toe  and  then  has  the  patient  wear  a  wooden  sandal  shaped  to 
the  sole  of  the  foot,  and  bandaged  firmly  to  hold  the  toes  down;  later  it  is 
worn  only  at  night.  It  is  adapted  especially  for  the  cases  of  contracture 
combined  with  talipes  cavus.  Single  toes  may  be  extended  forcibly  and 
bandaged  with  adhesive  plaster  to  a  small  elastic  metal  splint  covered 
with  felt.  Greater  curvatures  require  operation.  Division  of  the  skin, 
tendons,  and  capsule  on  the  flexor  surface  until  the  toes  can  be  stretched, 
followed  by  immobilization  for  from  three  to  four  weeks,  has  also  been 
recommended.  The  results  are  sometimes  good,  but  then  again  the 
joints  may  be  so  deformed  that  the  effect  is  only  temporary.  We  prefer 
therefore  to  resect  the  joints  through  a  dorsal  incision  and  to  excise  the 
bursa  and  divide  the  flexor  tendon.  If  the  toe  is  so  deformed  or  dis- 
placed as  to  be  useless,  amputation  is  preferable. 

( lontraction  of  the  plantar  fascia  and  of  the  toes,  analogous  to  Dupuy- 
tren's  contraction,  is  very  rare.  Hoffa  saw  such  in  a  patient  twenty 
years  old  developing  without  apparent  cause;  there  was  a  thickened 
band  in  both  feet  corresponding  to  the  inner  border  of  the  plantar  fascia. 
The  severe  pain  which  existed  was  relieved  by  excision.  The  specimen 
showed  inflammation  of  the  plantar  fascia  and  spots  of  cartilaginous 
metaplasia.  Ledderhose  records  cases  of  cicatricial  nodules  in  the 
fascia  due  to  laceration,  the  pain  of  which  usually  disappeared  spon- 
taneously and  rarely  necessitated  excision.  Franke  saw  similar 
nodules,  but  painless,  appearing  after  influenza,  which  he  regarded  as 
inflammatory  and  designated  as  a  fasciitis  plantaris. 

Metatarsalgia. — Metatarsalgia,  a  painful  affection  of  the  metatarsus 
first  described  by  T.  G.  Morton,  the  etiology  of  which  is  similar  to  that  of 
contractures  of  the  toes,  has  been  taken  little  account  of  in  the  German 
literature.  After  or  in  the  absence  of  previous  slight  trauma,  severe 
pain  is  felt  in  the  region  of  the  fourth  metatarsophalangeal  joint.  It 
is  usually  increased  by  pressure  upon  the  joint  or  lateral  compression  of 
the  foot.  In  the  mild  cases  it  is  periodic  like  neuralgia;  in  severe 
eases  it  is  continuous  and  makes  walking  or  even  the  wearing  of  shoes 
impossible.  Usually  the  pain  diminishes  on  removing  the  shoe  or 
extending  the  foot  forcibly.  It  is  much  more  common  in  women  than 
in  men. 

It  may  also  involve  the  other  metatarsals.  Peraire  and  Mally  demon- 
strated with  the  .r-ray  that  it  was  due  to  deviation  or  subluxation  in  the 
metatarsophalangeal  joint;  the  resected  heads  of  the  metatarsals  showed 
a  proliferating  ostitis.     T.  G.  Morton  believed  that  it  was  due  to  com- 


858  DISEASES  OF  THE  ANKLE  AND  FOOT. 

pression  of  the  branches  of  the  external  plantar  nerve  between  the 
heads  of  the  fourth  and  fifth  metatarsal  from  wearing  tight  shoes. 
Narrow  and  short  shoes  unquestionably  favor  the  occurrence  of  devia- 
tion and  subluxation  of  the  toes,  for  occasionally  one  finds  the  toes 
clawed  and  the  pain  limited  to  the  plantar  surface  of  the  hyperextended 
metatarsophalangeal  joints.  The  same  pain  in  the  metatarsals  is 
present  in  beginning  flat-foot.  Lang  and  Seitz  have  called  attention  to 
the  pain  which  is  felt  in  the  heads  of  the  metatarsals  after  correction  of  a 
talipes  equinus  or  varus,  and  which  is  due  to  pressure  upon  new  and 
unaccustomed  points  and  the  consequent  irritation  of  the  periosteum. 
The  affection  is  very  stubborn  and  the  treatment  protracted.  As  a  rule 
the  treatment  is  limited  to  prescribing  broad  shoes,  baths,  gentle  mas- 
sage, and,  as  suggested  by  Lange  and  Seitz,  a  felt  sole  with  holes  situ- 
ated under  the  painful  points.  We  have  never  had  occasion  to  resect 
the  fourth  metatarsophalangeal  joint,  as  performed  successfully  by  S.  K. 
Morton  in  severe  cases,  or  to  resect  the  head  of  the  metatarsal,  as  recom- 
mended by  Peraire  and  Mally. 

[According  to  Whitman,1  "the  more  distinctive  term  anterior  meta- 
tarsalgia,  a  term  suggested  by  Poulosson,  of  Lyons,  in  1889,  may  be 
employed  to  include  Morton's  neuralgia  and  similar  symptoms  of  pain 
and  discomfort  about  the  anterior  metatarsal  arch.  For  in  many 
instances  the  cramp-like  pain  is  referred  to  other  points,  for  example, 
to  several  adjoining  joints,  or  the  discomfort  caused  apparently  by 
direct  pressure  on  the  bones  of  the  weakened  arch  may  be  more  trouble- 
some than  the  irregular  attacks  of  neuralgic  pain."  The  condition  is 
more  commonly  met  with  after  the  thirtieth  year,  in  private  than  in 
hospital  practice,  and  not  infrequently  the  patients  are  of  a  nervous 
type.  The  significance  of  anterior  metatarsalgia  has  been  made  more 
clear  recently  by  the  study  of  the  relation  of  weakness  of  the  anterior 
transverse  metatarsal  arch  to  the  symptoms.  "Attention  was  first 
called  to  this  point  by  Poulosson,  of  Lyons,  and  again  by  Roughton, 
Woodruff,  and  others,  and  in  a  much  more  convincing  manner  by 
Goldthwait,2  of  Boston,  in  1X94." 

Whitman  described  the  anterior  metatarsal  arch  as  follows:  if  one 
examines  a  normal  foot  one  notices  that  the  two  middle  metatarsal 
bones,  the  second  and  third,  are  slightly  longer  and  on  a  higher  plane 
than  their  fellows.  On  the  sole  of  the  foot  the  arch  is  shown  by  the 
depression  immediately  to  the  outer  side  of  the  muscular  projection 
of  the  great  toe-joint.  When  weight  is  borne  all  the  metatarsal  bones 
are  on  the  same  plane  and  the  arch  is  obliterated,  but  when  the  weight 
is  removed  the  arch  re-forms  with  a  certain  natural  resiliency.  In 
walking  and  standing  the  weight  is  balanced  on  the  head  of  the  third 
metatarsal  bone,  as  shown  by  a  thickening  of  the  skin  beneath  its  head, 
but  the  strain  on  the  metatarsal  arch  is  relieved  somewhat  by  the 
balancing  action  of  the  muscles  about  the  first  and  fifth  metatarsal 

['   Whitman's  Orthopedic  Surgery,  1903. 
2  Boston  Medical  and  Surgical  Journal,  vol.  cxxxi.  p.  233.] 


CONTRACTURES  AND  DEFORMITIES  OF  THE  TOES.        859 

bones,   the  inner  and   outer  supports  of  the  arch    (see   page  s-'!l    ,   and 
by  the  active  assistance  of  the  toes  themselves.    When  the  arch  is  weak 

or  broken  down  this  natural  resiliency  is  lost,  and,  in  .some  instant 
the  centre  of  the  forefoot  is  not  only  depressed,  hut  it  is  fixed  in  this 
abnormal  attitude. 

In  the  ordinary  type  of  depressed  anterior  arch  the  deformity  may 
he  shown  by  an  imprint  of  the  foot,  in  which  the  flabby  tissues  of  the 
depressed  arch  encroach  upon  the  clear  spaee  representing  the  longi- 
tudinal arch,  and  obliterate  what  Goldthwait  calls  the  re-entering  angle 
to  the  outer  side  of  the  great  toe-joint,  which  in  the  normal  foot  indicate. 
the  highest  point  of  the  metatarsal  arch.  In  many  instances,  however, 
the  imprint  of  the  foot  subject  to  Morton's  neuralgia  may  be,  to  all 
intents,  normal,  and,  on  the  other  hand,  depression  of  the  metatarsal 
arch,  one  of  the  very  common  results  of  improper  shoes,  may  be  present, 
yet  unaccompanied  by  pain  or  discomfort. 

Depression  of  the  anterior  arch,  the  result  of  the  loss  of  the  activity 
of  the  accessory  supports  of  the  arch,  predisposes  to  pain  because  of 
abnormal  pressure  upon  the  persistently  depressed  articulations  from 
beneath,  and  it  predisposes  to  pain,  as  the  writer  has  endeavored1  to 
explain,  because  the  metatarsophalangeal  joints  of  an  arch  that  is 
habitually  depressed  are  exposed  to  the  direct  lateral  compression  of 
a  narrow  or  ill-shaped  shoe. 

Anterior  metatarsalgia  is,  in  most  instances,  the  result  of  weakness 
or  depression  of  the  anterior  metatarsal  arch,  as  a  whole  or  in  part, 
and  the  quality  of  the  pain  corresponds  fairly  to  the  form  of  weakness 
or  deformity.  If,  for  example,  the  entire  arch  is  rigidly  depressed,  as 
in  certain  rheumatic  affections,  the  discomfort  is  likely  to  be  caused, 
in  great  degree,  by  the  direct  pressure  of  the  sensitive  depressed  meta- 
tarsophalangeal joints  on  the  sole  of  the  shoe;  or,  if  lateral  pressure 
is  exerted  as  well,  the  discomfort  or  the  pain  may  be  referred  to  the 
metatarsal  arch  in  general.  If  the  metatarsal  arch  is  weakened,  de- 
pressed, and  broadened,  but  not  rigid,  the  discomfort  is  then  referred, 
as  in  the  preceding  instance,  to  the  centre  of  the  arch,  and  this  dis- 
comfort is  increased,  in  some  instances,  by  a  painful  callus  representing 
abnormal  pressure  at  this  point.  If  one  of  the  metatarsal  bones  falls 
below  its  fellows,  the  lateral  pressure  of  a  narrow  shoe  may  cause 
neuralgic  pains  at  this  joint;  but  in  many  cases  in  which  the  anterior 
arch  is  depressed  the  patient  makes  but  little  complaint  of  pain.  In 
certain  instances,  more  particularly  those  of  Morton's  typical  neuralgia, 
the  foot  may  appear  to  all  intents  normal;  in  such  cases  it  may  be 
inferred  that  the  sharp  and  characteristic  pain  is  caused  by  pressure 
applied  to  the  overriding  fifth  metatarsal  bone,  just  as  similar  pain  is 
felt  if  the  hand  is  suddenly  compressed  while  the  fifth  metacarpal  bone 
is  in  the  same  position.  This  theory  is  the  more  probable  when  one 
considers  the  symptoms;  for  example,  the  sensation  of  something 
slipping  or  moving,  the  necessity  for  the  removal  of  the  shoe  to  flex 

[!  Whitman,  New  York  Medical  Record,  August  6,  189S.] 


360  DISEASES  OF  THE  ANKLE  AND  FOOT. 

and  extend  the  toes  and  to  compress  the  foot,  apparently  with  the 
instinctive  aim  of  replacing  a  depressed  arch  or  a  misplaced  bone  in 
the  arch.  It  would  also  explain  how  the  shoe  may  be  the  most  direct 
of  the  exciting  causes  of  the  deformity,  in  that  it  compresses  the  forepart 
and  throws  more  weight  upon  it  by  elevating  the  heel.  If  the  arch  is 
depressed  or  becomes  depressed,  or  if  a  bone  in  the  arch  overrides 
another,  this  compression  causes  the  symptoms. 

The  shoe  is,  therefore,  not  only  the  direct  cause  but  also  the  most 
important  of  the  predisposing  causes  in  compressing  the  toes,  lifting 
them  off  the  ground  by  its  "rocker  sole,"  and  thus,  by  preventing  their 
normal  function,  throwing  additional  strain  and  pressure  upon  the 
arch.  In  a  large  proportion  of  the  feet  that  are  supposed  to  be  normal 
in  appearance  and  functional  ability  Whitman  found  the  toes  habit- 
ually dorsi-flexed  in  a  claw-like  attitude,  showing  entire  disuse  of  the 
function  both  as  to  support  and  progression.  He  attributed  the  greater 
frequency  of  the  affection  in  women  to  the  fact  that  they  wore  shoes 
with  narrower  soles  and  higher  heels  than  men.  The  shoe  also  pre- 
disposes to  habitual  elevation  of  the  fifth  metatarsal  bone,  because  this 
bone  almost  invariably  overhangs  the  narrow  sole.  The  fourth  meta- 
tarsal thus  becomes  the  outer  support  of  the  arch,  and  is  almost  always 
found  on  a  lower  level  than  the  adjoining  bones.  This  relation,  together 
with  a  laxity  of  muscular  and  ligamentous  support  induced  by  injury 
or  otherwise,  may  account  for  the  location  of  the  pain  at  this  point 
in  the  majority  of  the  cases.  Although  in  certain  instances  a  neuritis 
may  follow  direct  injury,  yet  this  assumption  is  not  at  all  necessary  to 
explain  the  symptoms.  Nor  is  it  likely  that  the  peculiar  distribution  of 
the  nerves  at  this  point  has  any  direct  influence  on  the  pain,  for  the 
nerve  supply  of  all  the  joints  and  all  the  toes  is  practically  identical. 

As  further  contributing  causes  Whitman  notes  the  possible  influence 
of  inherited  predisposition,  weakness  or  direct  injury  of  the  anterior 
arch,  weakness  of  the  longitudinal  arch,  flat-foot,  abnormal  shortness  of 
the  tendo  Achillis  producing  more  pressure  on  the  front  of  the  foot,  and, 
in  connection  with  these  causes,  corns  and  callus  beneath  the  depressed 
bones — a  common  occurrence.  In  some  cases  the  symptoms  can  only 
be  accounted  for  by  a  local  neuritis;  in  others  they  are  aggravated  by 
gout  or  rheumatism  or  general  debility.  As  mentioned,  in  a  large 
proportion  of  the  cases  the  patients  are  of  a  distinctly  nervous  type. 

The  rational  treatment,  therefore,  according  to  Whitman,  consists 
primarily  in  the  wearing  of  proper  shoes  (Fig.  547)  with  broad,  thick 
soles,  a  high  arch,  as  suggested  by  Gibney,  to  remove  part  of  the  press- 
ure from  the  heads  of  the  metatarsals,  and  a  low  heel.  Other  measures 
to  be  considered  are:  a  firm  bandage  about  the  metatarsal  region,  or, 
better,  an  adhesive-plaster  strap;  a  pad  beneath  or  slightly  behind  the 
affected  joint  or  arch,  as  suggested  by  Poulosson  and  Goldthwait, 
preferably  an  oval  of  sole  leather,  with  bevelled  edges  and  about  one 
inch  by  three-quarters  in  size  and  one  quarter  in  thickness,  to  be 
fastened  in  the  shoe  after  the  proper  bearing  has  been  ascertained; 
finally,  a  metal  brace.     (Fig.  577.)    The  latter  is  more  comfortable  and 


CONTRACTURES  AND  DEFORMITIES  OF  THE  TOES. 


861 


Fig.  577. 


far  more  efficient.  It  may  be  made  of  light  steel  (19  gauge)  moulded 
upon  a  plaster  cast  of  the  foot,  with  the  natural  depressions  somewhat 
exaggerated.  If  several  metatarsophalangeal 
joints  are  sensitive  it  may  be  made  the  length 
of  the  toot  and  worn  as  a  splint  to  prevent  mo- 
tion for  a  while.  Flattening  of  the  longitudinal 
arch  may  be  corrected  by  raising  the  inner  border 
of  the  heel  and  sole,  or,  if  pronounced,  a  flat- 
foot  brace  (Fig.  553)  may  be  used,  modified  in 
front,  as  in  (Fig.  577),  to  support  the  metatarsal 
arch.  On  the  other  hand,  exaggerated  arch  or 
limited  dorsal  flexion  require  their  appropriate 
treatment. 

If  the  arch  is  rigidly  depressed,  manipulation 
or  forcible  correction  under  anaesthesia  are  neces- 
sary before  applying  the  brace.  In  acute  cases, 
especially  after  injury,  the  foot  should  be  rested 
and  the  arch  elevated  and  supported  by  a  prop- 
erly applied  plaster  bandage. 

In  all  cases  the  temporary  measures  should  be 
followed  by  massage,  regular  exercise  of  the  mus- 
cles, proper  functional  use  of  the  foot  and  espe- 
cially methodical  forced  flexion  of  the  toes  to 
increase  the  anterior  metatarsal  arch.     (Fig.  578.) 

In  chronic  and  persistent  cases  the  head  and 
neck  of  the  metatarsal  are  resected,  as  employed   uiation.    (Whitman.) 
by  Morton. 

Removal  of  a  sensitive  callus  beneath  the  arch  may  be  necessary 
in  some  cases  and,  in  connection  with  proper  shoes,  may  be  effectual, 


A  brace  for  anterior  meta- 
tarsalgia.  A  indicates  a  point 
beneath  the  fourth  meta- 
tarsophalangeal articulation, 
which  is  elevated  in  order  to 
support  the  depressed  artic- 


FlG.  578. 


Exercise  for  the  weakened  metatarsal  arch.     (Whitman.) 


but,  as  a  rule,  a  cure  is  possible  only  by  overcoming  the  common  cause 
of  the  callus,  namely,  the  habitual  depression  of  one  or  more  of  the 


862  DISEASES  OF  THE  ANKLE  AND  FOOT. 

metatarsophalangeal  articulations,  by  supporting  the  arch  and  strengthen- 
ing its  natural  supports  in  the  manner  already  described. 

The  general  condition  is  to  he  regarded:  local  applications,  electricity 
and  the  like  may  he  of  benefit  in  special  cases.] 


DISEASES  OF  THE  VESSELS  AND  NERVES   OF  THE  FOOT. 

Aneurism  in  the  Foot. — Aneurism  is  rare  in  the  foot.  It  usually 
affects  the  dorsalis  pedis  artery,  and  is  generally  traumatic.  In  1889 
Chauvel  could  only  collect  20  cases  of  this  sort.  Plantar  aneurism  is 
very  rare,  and  arteriovenous  aneurisms  have  hardly  ever  been  seen. 

There  is  usually  no  disturbance  until  the  aneurism  is  quite  large.  It 
may  finally  erode  the  bones  and  joints  and  entirely  disable  the  foot.  The 
sac  and  surrounding  tissues  become  inflamed  rather  frequently. 

Diagnosis. — The  diagnosis  of  aneurism  on  the  dorsum  is  not  difficult, 
on  account  of  its  superficial  position,  unless  it  is  filled  with  clots  and 
without  distinct  pulsation  or  unless  a  phlegmonous  inflammation  exists 
in  the  surrounding  tissues.  In  the  latter  case  it  may  be  confused  with 
abscess.  In  the  sole  the  diagnosis  is  more  difficult.  If  the  sac  is  inflamed, 
it  is  even  more  liable  to  be  confused  with  abscess. 

Treatment. — Treatment  by  means  of  direct  or  indirect  pressure  or 
mere  ligation  of  the  artery  is  rather  uncertain.  The  artery  should  be 
ligated  above  and  below  and  the  sac  opened  and  obliterated  or  excised. 
This  is  done  easily  on  the  dorsum  and  without  much  difficulty  in  the 
sole.  (See  Popliteal  Aneurism.)  (For  phlebectasia  in  the  foot  see 
section  on  Varicose  Veins.) 

Gangrene  of  the  Foot. — The  foot  is  the  favorite  site  of  the  various 
forms  of  spontaneous  gangrene. 

Senile  Gangrene. — The  most  common  causes  are  the  senile  changes 
in  the  heart  and  vessels,  namely,  arteriosclerosis.  In  some  cases 
symptoms  of  impoverished  circulation  have  existed  for  a  long  time 
previously;  coolness,  numbness,  pains  of  a  rheumatic  or  neuralgic 
character.  In  others  these  prodromal  symptoms  are  absent,  and, 
without  apparent  cause,  a  small  brownish  gangrenous  spot  appears 
in  the  skin  of  the  toe  and  gradually  extends  and  involves  one  or 
more  toes.  Demarcation  often  takes  place  at  this  point,  but  more 
frequently  the  gangrene  is  attended  with  inflammatory  symptoms 
spreading  over  the  foot.  The  inflamed  parts  are  very  painful,  bluish- 
red,  and  oedematous.  Gradually  this  bluish-redness  becomes  livid 
and  then  black,  like  the  gangrenous  parts;  at  first  this  is  chiefly  con- 
fined to  the  toes.  This  form  is  apt  to  follow  slight,  often  invisible 
injuries,  frostbites,  application  of  strong  carbolic  acid,  etc.  The 
slight  injuries  are  frequently  inflicted  in  cutting  the  nails  or  corns, 
etc.,  to  relieve  the  prodromal  pain  which  is  attributed  by  the  patient 
to  the  pressure  of  the  nail  or  corn.  If  the  gangrene  is  inflammatory 
—moist  gangrene — from  the  outset  or  a  dry  gangrene  becomes  infected, 
the  process  is  apt  to  spread  more  rapidly  over  the  foot  and  leg.     The 


DISEASES  OF  THE  VESSELS  AND  NERVES  OF  THE  FOOT,     si;:; 

gangrenous  parts  are  moist  and   putrid;  phlegmon  and   lymphangitis 
may  spread  up  the  liml>,  accompanied  by  rather  high  fever. 

Diminished  heart  action  and  atheromatous  changes  in  the  vessels  are 
unquestionably  the  causes  of  senile  gangrene.  Bui  the  gangrene  may 
develop  in  various  ways.  Often  a  marantic  thrombosis,  beginning  in  the 
capillaries  and  smaller  vessels  of  the  mosl  distal  parts  of  the  extremity 
and  gradually  spreading,  is  the  immediate  cause.  Naturally  it  occurs 
mosl  easily  after  injuries  and  inflammations.  Multiple  thrombosis  of 
the  larger  vessels  has  also  been  found  as  the  result  of  arteriosclerosis  and 
regarded  as  the  cause.  Heidenhain  assumes  that  this  is  more  apt  to 
produce  dry  gangrene.  It  is  still  a  matter  of  question  (Landow)  whether 
gangrene  inevitably  follows  thrombosis  of  one  or  more  of  the  larger 
vessels  and  so  frequently  (according  to  Heidenhain,  in  over  50  per  cent, 
of  the  cases). 

Fig.  579. 


Senile  gangrene  of  foot.     (Solley.) 

Presenile  Gangrene. — The  term  "  presenile  gangrene"  has  recently  been 
applied  to  a  form  occurring  in  younger  persons  as  the  result  of  vascular 
changes.  It  occurs  between  the  twentieth  and  fiftieth  year;  when  seen 
previous  to  the  twentieth  year  it  is  termed  infantile  or  juvenile  gangrene. 
The  symptoms  are  often  characteristic.  While  resting  the  patient  feels 
perfectly  well,  but  after  walking  for  a  certain  length  of  time  sensory, 
motor,  and  vasomotor  disturbances  develop  in  the  leg,  and  especially  in 
the  foot,  in  the  form  of  paresthesias,  itching,  tingling,  cyanosis,  cold- 
ness, numbness,  and  weakness,  which  disappear  after  resting  but  recur 
on  walking,  so  that  the  patient  has  to  rest  at  intervals.  The  term 
"intermittent  limp"  has  been  applied  to  this  phenomenon.  (Charcot, 
Eib,  Goldflam.)  In  the  early  stages  the  pulse  in  the  arteries  of  the 
foot  is  small  or  absent,  as  evidence  of  the  already  existing  arteritis. 
Many  of  the  patients  become  morphine  subjects  on  account  of  the 
intense  pain.     A  gangrenous  ulcer — moist  gangrene — develops  from  a 


864  DISEASES  OF  THE  ANKLE  AND  FOOT. 

small  wound  or  without  apparent  cause  and  spreads,  accompanied  by 
severe  pain. 

The  changes  found  in  the  vessels  are  extensive  obliteration  of  the 
arteries  and  thickening  of  the  intima  of  the  veins.  The  process  was 
regarded  by  v.  Winiwarter  and  Billroth  as  an  obliterating  or  hyperplastic 
endarteritis,  beginning  in  the  large  vessels  of  the  leg  and  spreading 
downward;  by  Weiss  as  the  result  of  thrombosis  due  to  endarteritis. 

The  closure  of  the  vessel  above  diminishes  the  blood-supply  to  the 
still  open  distal  portions  of  the  artery,  thus  altering  the  relation  between 
the  lumen  of  the  vessel  and  the  amount  of  blood.  This  misrelation 
gives  rise,  according  to  Thoma,  to  a  compensatory  narrowing  of  the 
lumen,  an  endarteritis  with  contraction  of  the  media  and  growth  of  the 
intima.  In  this  way  Weiss  explains  the  fact  that  thickening  is  present 
in  the  intima  of  the  peripheral  and  only  partially  closed  smaller  vessels. 
According  to  Weiss,  "  the  gangrene  is  ultimately  due  to  the  usual  sclerotic 
changes  in  the  vessels,  only  that  here  the  sclerosis  gave  rise  to  the  gan- 
grene not  directly,  but  indirectly  through  the  thrombosis."  The  origin 
was  therefore  the  same  as  in  many  cases  of  senile  gangrene,  the  only 
difference  being  that  in  youthful,  better-nourished  individuals  the  col- 
lateral circulation  was  sufficient  to  retard  the  spreading  of  the  gangrene. 
Borchard  accepted  v.  Winiwarter's  view,  but  more  recent  investigators 
(Bunge,  Wulff,  Matanowitsch)  side  with  Zoege  v.  Manteuffel  and  Weiss. 
Bunge  regards  presenile  gangrene  as  the  result  of  premature  arterio- 
sclerosis, which  usually  produces  multiple,  rarely  single,  stenoses,  and  is 
very  apt  to  develop  at  the  giving-off  points  of  the  collaterals.  The 
thickening  of  the  muscularis,  narrowing  of  the  lumen  of  the  vessels, 
and  the  relatively  slight  growth  of  the  intima  found  by  many  observers 
would  indicate  (Wulff)  that  the  gangrene  in  many  cases  is  due  primarily 
to  abnormal  vasomotor  constriction,  secondarily  to  changes  in  the 
vessels  analogous  to  those  in  Raynaud's  angiospastic  gangrene.  The 
causes  of  early  degeneration  of  the  vessels  are  frequently  the  action  of 
cold,  abuse  of  alcohol  and  nicotine,  and  syphilis. 

Diabetic  Gangrene. — Diabetic  gangrene,  although  known  for  a  long 
while  and  studied  more  closely  after  the  publications  of  Marchal  de 
Calvi  and  Griesino-er,  has  onlv  recentlv  claimed  the  attention  of  German 
surgeons  since  W.  Roser's  well-known  work.  Its  frequency  is  due  to  two 
circumstances:  the  great  susceptibility  of  diabetic  subjects  to  purulent 
and  septic  infections  and  their  sequela?,  carbuncle,  phlegmon,  etc.,  and 
the  very  early  appearance  of  arteriosclerosis  in  diabetes.  Diabetic 
gangrene  occurs  not  only  in  older  subjects  with  impaired  vitality,  but 
also  in  younger,  apparently  healthy  individuals.  It  is  rare  before  the 
thirty-fifth  year.  The  age,  together  with  the  fact  that  arteriosclerosis  is 
met  with  in  the  majority  of  cases  of  diabetes,  even  in  relatively  young 
subjects,  show  the  significance  of  vascular  degeneration.  In  the  cases  of 
diabetes  associated  with  arteriosclerosis  diabetic  gangrene  would  there- 
fore be  angiosclerotic,  in  a  certain  sense  an  early  senile  gangrene.  The 
susceptibility  of  diabetic  tissues  to  severe  traumatic  infections  and 
necrotic  inflammations  gives  diabetic  gangrene  a  peculiar  character; 


DISEASES  OF  THE  VESSELS  AND  NERVES  OF  THE  FOOT.      gQ§ 

gangrene  of  the  foot  and  leg  is  a  frequent  occurrence  in  diabetic  sub- 
jects as  the  result  of  phlegmonous  inflammation  in  the  absence  of  any 
great  amount  of  arteriosclerosis.  It  is  for  this  reason  that  the  process 
is  commonly  a  moist  gangrene,  often  phlegmonous,  developing  more 
rapidly  than  the  senile  form,  and  with  less  tendency  to  demarcation 
and  spontaneous  recovery. 

Frostbite  Gangrene. — Frostbite  gangrene  does  not  generally  come 
under  observation  until  it  has  existed  for  several  days.  The  foot  and 
often  the  leg  are  greatly  swollen,  the  distal  parts  cold,  bluish-red,  and 
usually  anaesthetic,  but  still  very  painful.  -The  skin  is  very  tense  and 
the  epidermis  raised  by  wheals  at  various  points.  Gangrene  develops 
rapidly,  and  its  extent  cannot  be  foreseen.  If  improperly  treated,  it 
very  often  becomes  moist,  putrid,  and  accompanied  by  phlegmon, 
which  spreads  the  gangrene;  less  frequently  the  parts  mummify  and 
are  cast  off  spontaneously. 

Embolic  Gangrene. — Gangrene  due  to  embolism  of  the  main  arterial 
trunks,  chiefly  the  femoral  or  popliteal,  is  more  rare.  The  embolism  is 
usually  the  result  of  endocarditis.  Embolism  or  thrombosis  may  occur 
during  or  after  a  severe  infectious  disease  (typhoid,  measles,  scarlet 
fever,  pneumonia,  influenza)  and  produce  gangrene  of  the  leg  in  the 
absence  of  any  endocarditis.  Contusion  of  the  femoral  artery  has  been 
followed  by  thrombosis  and  gangrene  of  the  leg.  Cases  of  presumably 
secondary  thrombosis  or  embolism  of  one  lower  extremity  have  followed 
severe  contusion  of  the  thorax  or  abdomen ;  in  several  cases  the  gangrene 
followed  in  eight  or  nine  days  after  the  injury. 

In  a  number  of  instances  in  children  and  adults  a  circumscribed 
patch  of  endarteritis  of  the  femoral  artery,  of  syphilitic  or  unknown 
origin,  has  given  rise  to  gangrene  of  the  foot.  Syphilitic  arteritis  has 
been  repeatedly  followed  by  symmetrical  gangrene  of  the  feet,  hands,  or 
other  parts  of  the  body.  Some  of  the  cases  were  looked  upon  as  being 
Raynaud's  angiospastic  gangrene,  because  the  prodromal  symptoms — 
temporary  suspension  of  circulation,  etc. — were  similar.  The  author 
believes  that  these  syphilitic  cases  and  the  angiosclerotic  cases  in  young 
subjects,  in  which  circulatory  disturbances  occasionally  appear  before 
the  gangrene,  and  in  which  the  gangrene  can  be  symmetrical,  should 
not  be  classified  as  yet  with  the  etiologically  obscure  Raynaud's  gangrene'. 

Raynaud's  Gangrene. — Raynaud's  gangrene  is  usually  ushered  in  by 
general  nervous  and  mental  disturbances.  The  feet  become  paresthetic, 
sometimes  cold  and  pale,  or  cyanotic;  the  attacks  vary  in  intensity  and 
duration,  and  are  occasionally  accompanied  by  severe  pain.  The 
symptoms  may  persist  unchanged  for  years  or  decades,  writh  remissions 
and  improvement,  but  gangrene  follows  in  severe  cases.  Raynaud  refers 
the  process  to  a  spastic  contraction  of  the  vessels,  due  to  altered  inner- 
vation of  the  vessels  of  central  origin.  The  author  believes  with  Oppen- 
heim  that  in  some  instances  it  may  be  an  independent  disease,  but 
in  others  it  is  merely  a  symptom  observed  in  other  nervous  diseases 
(hysteria,  tabes,  epilepsy,  syringomyelia,  etc.). 

Gangrene  due  to  ergotism  is  now  a  great  rarity. 
Vol.  III.— 55 


866  DISEASES  OF  THE  ANKLE  AND  FOOT. 

Treatment. — In  all  these  varieties  the  essential  is  to  avoid  infection  of 
the  dry  gangrene  and  to  transform  the  moist  into  the  dry  form.  The 
limb  should  therefore  be  sterilized  and  wrapped  in  dry  aseptic  gauze. 
Moist  gangrene  should  be  disinfected  and  deodorized  with  powder  or 
wet  dressings  of  boric  acid,  chlorine-water,  or  aluminum  acetate. 
Stronger  and  poisonous  remedies  should  not  be  used  as  they  are  readily 
absorbed.  The  limb  should  be  elevated  and  demarcation  awaited 
unless  operation  becomes  necessary. 

Demarcation  should  be  awaited  in  senile  gangrene,  even  if  the  process 
extends  slowly,  as  it  usually  stops  in  the  foot  or  in  the  leg,  and  any  mild 
lymphangitis  which  occurs  yields  promptly  to  appropriate  treatment. 
The  stump  can  then  be  amputated  in  sound  tissue.  Early  operation  is 
indicated  if  there  are  severe  pain,  rapid  advance  of  the  gangrene,  marked 
inflammation,  and  loss  of  strength.     The  prognosis  is  then  less  favorable. 

The  above  applies  in  much  the  same  way  to  diabetic  gangrene.  The 
majority  of  surgeons  prefer  to  await  demarcation,  put  the  patient  on  an 
antidiabetic  diet,  and  increase  the  general  strength.  The  glycosuria 
decreases  or  disappears  as  the  gangrene  becomes  limited.  Separation 
of  the  stump  is  rarely  to  be  expected,  but  the  prognosis  of  amputation 
becomes  more  favorable  if  the  amount  of  sugar  can  be  diminished, 
extension  of  the  gangrene  checked,  and  the  lymphangitis  overcome.  If 
the  percentage  of  sugar  remains  high  and  the  gangrene  advances  rapidly 
with  fever  and  acute  inflammation,  the  general  strength  diminishes 
rapidly.  These  cases  are  apt  to  be  in  younger  subjects  with  a  very  high 
percentage  of  sugar.  In  older  patients  with  a  lower  percentage  of 
sugar,  even  with  marked  atheroma  and  a  rather  pronounced  albuminuria, 
high  amputation  may  be  successful  in  spite  of  the  rapidly  advancing 
moist  gangrene.  The  prognosis  of  amputation  in  general  is  bad.  The 
diminution  of  sugar  following  amputation  or  demarcation  can  be  under- 
stood from  the  fact  that  a  temporary  glycosuria  is  frequently  seen  during 
suppuration  in  non-diabetic  patients. 

The  level  at  which  to  amputate  has  been  a  much  disputed  question. 
If  single  toes  are  affected,  amputation  can  be  performed  safely  in  the 
foot  or  low  in  the  leg.  If  the  gangrene  extends  above  the  ankle,  some 
surgeons  advise  to  always  amputate  in  the  thigh.  (Heidenhain.)  This 
generalization  has  met  with  decided  opposition.  (Konig,  Landow.)  If 
demarcation  is  distinct  we  may  amputate  according  to  Pirogoff  or  in 
the  leg.  If  the  process  is  advancing  or  phlegmonous,  or  the  main 
arteries  are  sclerotic  or  occluded,  amputation  of  the  thigh  is  preferable 
as  a  rule.  There  seems  to  be  no  question  that  amputation  in  the  leg 
can  be  successful,  even  when  the  main  arteries  of  the  leg  are  occluded 
(Landow),  but  it  also  seems  venturesome  to  attempt  it.  The  author 
considers  that  occlusion  of  the  main  trunks  has  a  greater  significance 
in  senile  and  diabetic  gangrene  than  that  assigned  to  it  by  Landow.  As 
far  as  a  general  rule  is  possible,  amputation  should  be  in  fairly  sound 
tissues;  this  presupposes  patency  of  the  more  important  arteries.  Even 
this  rule  has  its  exceptions,  for  occasionally  one  finds  the  femoral  closed 
on  amputating  in  the  thigh. 


NEUROPATHIC  AFFECTIONS  OF  THE  FOOT.  3^7 

In  the  treatment  of  the  seven-  pain  and  the  circulatory  disturbances 
of  the  prodromal  stage  of  angiosclerotic  gangrene  in  younger  subjects, 
Zoege  v.  Manteuffel  warns  against  massage  and  dietetic,  thermic,  and 
mechanical  measures  as  being  injurious  to  the  circulation,  and  advises 
rest,  elevation  of  the  limb,  exercises  to  strengthen  the  heart,  and  warm 
baths.  Erb  recommends  the  prolonged  use  of  potassium  or  sodium 
iodide.  If  gangrene  occurs,  demarcation  is  rarely  to  be  expected. 
The  rapid  extension,  the  pain  and  loss  of  strength  are  all  urgent  indica- 
tions for  amputation.  Zoege  v.  Manteuffel  recommends  Gritti's  exar- 
ticulation  at  the  knee,  as  after  amputation  lower  down  healing  is  less 
favorable  and  the  severe  pain  is  apt  to  continue  from  the  irritation  of 
the  nerve  stumps. 

In  frostbite  gangrene  demarcation  should  be  awaited,  the  limb  being 
elevated  or  suspended,  (v.  Bergmann  and  others.)  If  phlegmon  occurs, 
it  should  he  treated  appropriately.  Amputation  higher  up  may  be 
necessary  if  the  phlegmonous  process  spreads,  accompanied  by  high 
fever.  The  position  of  the  cicatrix  is  important;  if  amputation  is  per- 
formed in  the  foot  the  cicatrix  is  very  apt  to  become  ulcerated  later 
on  account  of  the  circulatory  disturbance  due  to  venous  congestion. 

In  the  other  forms  of  gangrene,  the  rules  for  amputation  are  about 
alike.  In  the  cases  due  to  embolism  and  thrombosis  the  situation  of 
the  thrombus  is  conclusive;  in  those  due  to  syphilis  and  neuropathic 
disturbances  the  stump  can  usually  be  removed  close  to  the  line  of 
demarcation.  In  single  instances  of  syphilitic  endarteritis  gangrene  has 
been  averted  by  specific  treatment. 

In  general  all  bleeding  points  should  be  carefully  ligated,  the  flaps 
should  not  be  made  too  tight  or  too  loose,  and  pressure  in  applying  the 
dressings  avoided.  If  the  wound  is  clean,  it  may  be  closed  partially 
and  drained;  otherwise  it  should  be  packed  loosely,  left  open,  and 
drained  until  all  inflammation  has  subsided,  then  sutured  secondarily 
or  allowed  to  heal  in  by  granulation. 


NEUROPATHIC  AFFECTIONS   OF  THE  FOOT. 

Perforating  Ulcers  of  the  Foot. — Perforating  ulcer  of  the  foot  (mal 
perforant  du  pied  of  Xelaton)  is  a  chronic,  painless  ulcer  which  is  apt 
to  invade  the  deeper  parts,  to  recur,  and  to  resist  all  forms  of  treatment. 
It  is  characterized  especially  by  anaesthesia  or  analgesia  which  may  be 
confined  to  the  area  about  the  ulcer,  or  occur  in  patches  or  diffusely  over 
the  entire  foot.  The  usual  seat  of  the  ulcer  is  in  the  sole,  particularly 
under  the  metatarsophalangeal  joints  (first  and  fifth  toe),  and  under  the 
heel,  namely,  the  points  of  support  of  the  foot.  It  is  also  found  at  other 
points  in  the  foot,  but  less  frequently. 

Very  often  there  is  at  first  a  growth  of  epithelium,  a  hyperkeratosis, 
under  which  suppuration  occurs  as  the  result  of  trauma,  and  then  perfora- 
tion. The  suppuration  may  start  in  an  accidental  bursa  beneath  the 
growth.     The  resulting  ulcer  is  small,  with  vertical,  undermined  edges, 


868  DISEASES  OF  THE  ANKLE  AND  FOOT. 

and  surrounded  by  thickened  epidermis;  it  has  but  little  tendency  to 
heal.  It  burrows  into  the  tendon-sheaths,  the  joint,  or  the  bone.  Excep- 
tionally temporary  recovery  takes  place  spontaneously,  but  on  account 
of  the  analgesia  the  ulcer  is  usually  neglected,  discharges  a  viscid 
foul  pus,  and  leads  to  suppuration  of  the  joint,  necrosis  of  the  bone,  or 
even  severe  ichorous  phlegmon.  The  course  is  generally  very  slow  and 
extends  over  years. 

In  the  majority  of  cases  the  condition  is  due  to  nervous  disturbances, 
and  is  almost  always  accompanied  by  abnormalities  of  sensibility, 
anaesthesia  or  analgesia  at  or  near  the  ulcer,  and  frequently  by  neuro- 
trophic changes  in  the  nails,  skin  and  bones,  pareses,  and  abnormal 
reflex  irritability.  As  first  demonstrated  by  Duplay  and  Morat,  and 
confirmed  later  by  other  authors  (v.  Bruns,  H.  Fischer,  and  others),  it  is 
a  neuroparalytic  ulcer  of  central  or  peripheral  origin,  the  most  frequent 
causes  being  tabes,  general  paralysis,  syringomyelia,  injuries  and  dis- 
eases of  the  spine  with  secondary  lesions  of  the  cord,  and  spina  bifida; 
the  somewhat  less  frequent  peripheral  causes  are  trauma,  tumors  of  the 
nerves  and  all  forms  of  neuritis.  Inflammatory  changes— hyperplastic 
neuritis — are  often  found  in  the  nerves. 

To  the  author  the  term  mal  perforant  does  not  imply  necessarily  the 
existence  of  inflammatory  changes  in  the  nerves  about  the  ulcer.  Such 
changes  may  be  absent  in  cases  in  which  the  entire  clinical  picture  is 
that  of  a  typical  neuroparalytic  ulcer,  if  the  affection  is  of  central  origin. 
Then  again  it  is  in  the  se  very  cases  of  central  origin  that  they  are  found 
so  often.  The  changes  in  the  peripheral  nerves  are  most  probably  due 
to  irritation,  traumatic  or  inflammatory,  produced  by  the  ulcer. 

Neuritis  occurs  with  various  constitutional  diseases,  such  as  alcohol- 
ism and  diabetes.  The  neuritis  associated  with  diabetes  is  apparently 
a  frequent  cause  of  perforating  ulcer,  as  noted  by  Kirmisson  and  Jaennel. 
The  ulcer  may  be  coexistent  with  diabetic  gangrene  or  suppuration,  but 
is  to  be  distinguished  from  them.  It  also  occurs  in  leprosy,  but  here 
again  it  is  due  to  disease  of  the  nerves  found  in  leprosy  (lepra  anses- 
thetica),  not  to  the  leprosy  itself. 

The  term  mal  perforant  should  be  limited  to  ulcers  of  nervous  origin, 
as  ulcers  equally  stubborn  and  painless  occur  in  the  foot,  but  from 
entirely  different  causes,  for  example,  syphilitic  ulcers,  carcinoma, 
localized  gangrene,  and  the  ulcers  due  to  atheroma,  or  suppuration  of 
bursa?  under  callosities. 

Malum  perforans  pedis  is  therefore  a  neuroparalytic  ulcer.  Local 
trauma  is  undoubtedly  an  important  factor  in  the  etiology — that  is,  the 
exciting  cause — of  an  ulcer  associated  with  a  nervous  disease;  but  the 
latter  is  always  the  predisposing  cause.  The  form  and  extent  of  the 
ulcer  are  determined  by  the  repeated  insults  to  which  it  is  exposed  by 
reason  of  the  existing  analgesia. 

Treatment. — The  treatment  is  both  general  and  local:  Protection 
from  injury  by  means  of  absolute  rest,  and  from  infection  by  covering 
with  antiseptic  or  aseptic  dressing;  removal  of  the  thickened  edges  of 
the  ulcer,  resection  of   necrosed  bone  or  a  suppurating  joint;    general 


NEUROPATHIC  AFFECTIONS  OF  THE  FOOT.  869 

treatment  of  the  primary  disease.  Little  improvement  is  obtained  by 
genera]  treatment  in  the  majority  of  eases.  The  ulcer  may  heal,  but 
others  are  very  apt  to  break  out  in  other  places  unless  the  primary  dis- 
ease is  cured.  Ulcers  have  been  even  known  to  appear  on  the  stump 
after  amputation.  Recently  Sick  has  successfully  overcome  the  affection 
by  stretching  the  posterior  tibial  nerve  behind  the  inner  malleolus  or  the 
internal  and  external  plantar  nerves,  as  recommended  by  Chipault,  in 
addition  to  treating  the  ulcer  locally  (asepsis,  curetting,  etc.). 

Sensory  and  Trophic  Disturbances  of  the  Foot. — Sensory  and 
trophic  disturbances  due  to  syringomyelia  are  observed  much  less  fre- 
quently in  the  feet  than  in  the  hands.  Occasionally  cases  are  seen  giv- 
ing Morvan's  symptom-complex;  wheals,  panaritia  with  necrosis  of  the 
phalanges,  mal  perforant,  spontaneous  gangrene,  etc.  Trophic  disturb- 
ances are  found  more  frequently  associated  with  tabes,  such  as  dys- 
trophy of  the  skin  and  nails,  hyperidrosis,  local  fever,  mal  perforant,  etc. 
Even  more  important  are  the  arthropathies  which  are  found  so  very  fre- 
quently with  tabes,  and  rarely  with  syringomyelia,  progressive  paralysis, 
etc.  In  tabes  the  joints  of  the  toes  may  become  swollen  and  distended 
by  effusion,  the  ligaments  relaxed,  and  the  bones  deformed;  but  such 
primary  affections  of  the  joint  are  not  common.  Kredel  was  able  to 
collect  only  10  cases.  We  saw  one  case  of  multiple  ataxic  arthropathy 
in  which  several  joints  of  the  toes  were  involved.  The  metatarsophal- 
angeal joints,  especially  the  first,  are  apparently  the  ones  most  commonly 
affected.  Entire  phalanges  may  be  absorbed  without  suppuration  and 
give  rise  to  deformation  analogous  to  the  process  observed  in  a  few 
instances  in  the  fingers,  but  usually  the  diseased  joints  suppurate  and 
the  bones  become  necrotic  and  are  cast  off. 

Tabetic  disease  of  the  tarsus,  which  was  first  described  by  Charcot 
and  Fere  (pied  tabetique),  gives  an  almost  typical  picture.  The  process 
is  very  apt  to  begin  before,  as  well  as  in,  the  ataxic  stage,  and  develop 
insidiously  and  slowly;  less  frequently  it  develops  rapidly  after  injury. 
In  some  instances  it  produces  no  discomfort,  in  others  there  are  dull 
pains,  a  sense  of  heaviness,  and  numbness  or  formication  in  the  foot. 
Deformation  takes  place  in  the  course  of  several  weeks  or  months. 
The  dorsum  is  thickened.  In  most  of  the  cases  the  swelling  is  even 
more  marked  on  the  inner  border  of  the  foot,  at  the  scaphoid  and 
astragalus.  The  sole  is  flattened.  The  foot  may  be  abducted,  especially 
the  front  part  (tabetic  talipes  valgus),  and  everted,  or  adducted  and 
inverted,  and  also  extended  (varus  and  equino varus).  The  affection 
may  be  unilateral  or  bilateral.  According  to  the  amount  of  deformation 
present,  one  finds  abnormal  mobility,  crepitus,  etc.  Anatomically  the 
changes  found  were  those  of  a  high-grade  arthritis  deformans;  defects 
in  the  cartilages,  erosion  of  the  tarsal  bones,  destruction  and  obliteration 
of  the  old  joints,  and  the  formation  of  new  joint-surfaces.  The  bones 
were  greatly  altered,  either  fractured  or  worn  off.  The  .r-ray  showed 
the  existence  of  an  osteoporosis  similar  to  that  found  with  bony  tumors; 
the  contour  of  the  bones  was  obliterated,  the  trabecular  had  dis- 
appeared. 


870  DISEASES  OF  THE  ANKLE  AND  FOOT. 

Tabetic  arthropathy  of  the  tibiotarscd  joint  is  not  rare;  Kredel  collected 
25  cases.  The  joint  is  enlarged  by  effusion  or  by  thickening  of  the 
epiphysis  of  the  tibia  and  fibula,  and  in  the  severe  cases  is  usually 
loose.  The  position  of  the  foot  varies,  but  is  usually  a  high-grade 
talipes  varus.  The  astragalus  is  often  fragmented  and  dislocated,  the 
fragments  lying  as  free  bodies  in  the  joint.  (Rotter,  and  others.)  The 
articular  ends  of  the  tibia  and  fibula  are  widened  and  partly  united  to 
each  other  by  growth  of  the  periosteum.  Fractures  of  the  malleoli  and 
pseudarthroses  are  also  found.  The  enlargement  of  the  bones  may 
suggest  a  bony  tumor  previous  to  the  examination  of  the  nervous 
system. 

Treatment.— In  the  case  of  all  these  tabetic  diseases  of  the  bones  and 
joints  conservatism  is  the  rule;  the  foot  is  immobilized,  more  particu- 
larly after  fractures  of  the  malleoli,  sudden  exacerbations,  effusions  or 
inflammations,  and  protected  in  a  splint  or  apparatus  against  injury 
and,  if  possible,  further  deformation.  Resection  of  the  joint  is  without 
benefit  (compare  Schoonheid's  compilation  of  operative  results)  and 
therefore  inadvisable.  If  perforation  of  the  joint  and  suppuration  follow, 
amputation  is  the  best  treatment.  Deformed  and  troublesome  toes 
should  also  be  amputated.  Small  bones  which  have  become  necrotic 
as  the  result  of  perforating  ulcers  can  be  excised.  By  careful  treat- 
ment it  is  often  possible  to  effect  an  improvement,  a  gain,  however, 
which  is  not  infrequently  temporary. 


TUMORS  IN  THE  FOOT. 

Numerous  tumors  occur  in  the  foot,  few  of  which,  however,  acquire 
any  peculiarity  from  their  situation. 

Benign  Neoplasms. — Single  instances  of  fibroma,  neuroma,  keloid, 
etc.,  have  been  recorded.  Lipoma  is  somewhat  more  common,  is  most 
apt  to  be  situated  in  the  sole,  and  may  be  congenital.  (See  Congenital 
Hypertrophy. ) 

Simple  angioma  and  telangiectasis  show  no  peculiarities  in  children. 
Large  cavernous  angioma  and  phlebarteriectasis  (cirsoid  aneurism)  are 
rare.  The  symptoms  and  treatment  of  the  two  latter  diseases  are  the 
same  as  those  of  the  corresponding  tumors  in  the  hand,  where  they  are 
more  frequent. 

Chondroma  is  by  no  means  rare  in  the  foot,  and,  as  in  the  hand, 
develops  chiefly  in  the  medulla  of  the  phalanges  and  metatarsals  and 
is  apt  to  be  multiple.  It  is  found  less  frequently  in  the  tarsal  bones,  for 
example,  the  calcaneum.  On  account  of  its  relative  benignancy  one 
may  attempt  to  scrape  it  out  at  first,  or  to  resect  the  bones,  but  usually 
the  tumor  has  to  be  removed  by  amputation. 

Osteoma  has  been  seen  at  various  points  on  the  foot  and  rather  fre- 
quently in  the  heel.  In  the  latter  position  it  occasionally  starts  from 
the  calcaneum,  or  it  may  be  situated  in  the  soft  parts. 

Of  the  exostoses  from  the  bones  of  the  foot,  the  most  frequent  and 


TUMORS  IX  THE  FOOT  871 

most  interesting  are  the  subungual  growths  in  the  toes  which  were  first 
accurately  described  by  Dupuytren.  They  are  more  common  in  the 
great  toe  than  in  the  others  and  more  often  situated  under  the  nail  than 
at  the  edge.     They  are  seen  almost  entirely  in  young  individuals. 

The  etiology  of  this  form  of  exostosis  is  still  a  matter  of  discussion. 
Many  authors  (Virchow)  believe  that,  although  the  tumor  is  referable  in 
general  to  the  period  of  evolution,  it  should  be  classified  with  the  peri- 
osteal growths  due  to  irritation;  others  attribute  it  to  exuberant  growth 
of  the  cartilage  in  the  transition  stage.     The  fact  is  interesting  that  these 

o  O  o 

so-called  exostoses  are  sometimes  found  separated  from  the  bone  by 
fibrous  tissue,  namely,  that  they  are  periosteal  osteomata,  occasionally 
containing  cartilage. 

The  tumor  is  usually  small,  composed  of  thick  or  porous  bone, 
covered  with  thick  periosteum  or  a  layer  of  cartilage,  and  sometimes 
contains  cartilage.  It  may  develop  from  connective  tissue,  periosteum, 
or  cartilage.  It  grows  slowly,  and  gradually  lifts  and  loosens  the  nail. 
Sometimes  it  is  removed  partially  by  the  patient  to  relieve  the  pain 
caused  by  the  pressure  of  the  shoe.  The  diagnosis  is  often  difficult  at 
the  outset.     The  nail  should  be  extracted  and  the  growth  removed. 

The  so-called  traumatic  epithelial  cysts  sometimes  appear  in  the  sole 
after  injury  as  in  the  hand,  and  are  easily  cured  by  excision. 

Warts  and  larger  flat  papillomata  may  be  single  or  multiple  and  by 
reason  of  their  situation  cause  great  annoyance  and  pain.  They  can 
be  cauterized,  curetted,  or  excised.  Fibroma  and  leiomyoma  ( ?)  have 
also  been  reported. 

Malignant  Neoplasms. — Sarcoma  has  been  seen  in  a  few  instances  as 
a  congenital  tumor.  Sarcoma  of  the  skin  (sarcoma  molluscum)  is 
apt  to  develop,  as  in  other  parts  of  the  body,  from  congenital  warts  and 
nsevi,  and  may  or  may  not  contain  pigment,  Sarcoma  originating  in 
the  fascia,  ligaments,  and  tendon-sheaths  is  often  mistaken  at  the  outset 
for  tuberculous  abscesses,  etc.,  and  incised.  Subungual  sarcoma  can  be 
confused  with  the  corresponding  form  of  exostosis;  it  may  develop 
rapidly,  or  be  incapsulated  and  grow  slowly.  If  situated  on  the  edge  of 
the  nail,  it  can  be  mistaken  at  the  outset  for  an  ingrowing  nail.  Under 
the  name  of  calcified  endothelioma  Perthes  describes  two  tumors  situ- 
ated symmetrically  under  the  skin  of  the  soles,  which  were  similar  in 
structure  to  endothelioma  in  other  parts  of  the  body. 

Osteosarcoma  is  not  rare,  and  is  most  frequently  met  with  in  the 
metatarsals  and  phalanges.  Of  the  tarsals,  the  calcaneum  is  most 
often  affected,  in  accordance  with  its  apparent  predisposition  to  become 
the  seat  of  tumors.  The  growth  may  develop  from  an  enchondroma 
(Borchardt);  it  is  not  infrequently  confused  with  other  conditions, 
with  chronic  osteomyelitis  or  tuberculosis.  The  absence  of  symptoms 
of  inflammation  in  the  soft  parts  speaks  fcr  the  existence  of  a  tumor, 
although  chronic  osteomyelitis  and  tuberculosis  may  exist  for  a  long 
time  without  giving  such  symptoms.  The  a>ray  shows  the  presence  of 
a  peculiar,  uniform  transparency  in  the  structure  of  the  bone,  which  is 
absent  in  inflammatory  processes,  and  only  seen  otherwise  in  tabes. 


872  DISEASES  OF  THE  ANKLE  AND  FOOT. 

A  peculiar  disease  of  the  skin,  which  is  most  apt  to  appear  in  the  leg 
and  foot,  has  been  described  by  Kobner  under  the  name  of  multiple 
pigmented  sarcoma  or  hemorrhagic  sarcoma.  The  peculiarly  benign 
course  and  the  circumstance  that  the  growth  of  the  nodules  is  limited 
and  capable  of  receding  spontaneously,  make  it  probable  that  the 
process  is  a  chronic  infectious  disease. 

The  treatment  of  sarcoma  of  the  foot  is  not  in  any  way  exceptional. 
Subungual  angiosarcoma  is  readily  excised  after  removing  the  nail. 
Small  tumors  in  the  soft  parts  can  also  be  excised.  Larger  tumors  in 
the  soft  parts  and  osteosarcomata  demand  partial  or  complete  amputa- 
tion of  the  foot  on  account  of  the  liability  of  recurrence.  Two  cases  of 
sarcoma  of  the  calcaneum  are  known  in  which  excision  of  the  calcaneum 
and  removal  of  the  tumor  with  chisel  and  spoon  were  followed  by  cure 
lasting  for  a  long  period  of  time. 

Carcinoma  of  the  foot  is  usually  of  the  flat  epithelial  variety,  and  is  apt 
to  develop  from  old  cicatrices  due  to  trauma,  burns,  frostbites  (v.  Berg- 
mann),  or  ulcers,  or  from  chronically  irritated  spots,  such  as  callosities, 
corns,  etc.     It  develops  less  frequently  from  hard,  horny  warts. 

The  diagnosis  of  carcinoma  of  the  skin  is  not  difficult  unless  the 
growth  is  situated  in  the  sole.  There  it  may  be  confused  with  benign 
papilloma  if  small  and  not  ulcerated.  Carcinoma  can  be  distinguished 
from  perforating  ulcer  in  this  situation  by  the  fact  that  the  former  is 
usually  very  painful,  v.  Yolkmann  reports  a  case  of  pigmented  epithelial 
carcinoma  of  the  heel  and  sole;  this  form  is  relatively  favorable  if 
excised  radically  or  removed  by  amputation. 

Soft  myeloid  carcinoma  is  more  rare.  It  is  most  apt  to  develop  from 
congenital  moles  or  those  acquired  in  early  childhood,  but  also  occurs 
independently.  The  prognosis  of  soft  carcinoma,  particularly  when 
derived  from  a  congenital  mole,  is  very  unfavorable,  as  it  becomes 
rapidly  metastatic. 


CHAPTER  XXXIX. 

OPERATIONS  ON  THE  FOOT  AND  ITS  JOINTS. 

AMPUTATION  AT   THE  ANKLE. 

Syme's  Amputation. — Starting  at  the  tip  of  the  external  malleolus 
the  incision  is  carried  straight  across  the  sole  to  a  corresponding  point 
on  the  other  side,  \  inch  below  the  tip  of  the  internal  malleolus;  the 
dissection  is  then  carried  down  to  the  bone.  The  heel  is  dissected  back 
close  to  the  bone,  the  tendo  Achillis  divided  at  its  insertion,  the  tissues 

Fig.  580. 


1.   Incision  for  amputation  of  the  great  toe.      2.  Pirogoff's  incision  for  amputation  of  the  foot. 

(v.  Bergmann.) 

Fig.  581. 


Line  of  division  of  bones  according  to  Pirogoff.     (v.  Bergmann.) 


on  the  dorsum  divided  straight  across  between  the  ends  of  the  first 
incision,  the  astragalus  disarticulated,  the  end  of  the  tibia  and  fibula 
freed  and  sawed  off  straight  across  just  above  the  joint,  and  the  anterior 
and  posterior  arteries  ligated.  The  heel-flap  is  turned  forward,  sutured, 
and  drains  inserted  at  the  sides. 

Pirogoff's  Osteoplastic  Amputation  (Figs.  580  and  581). — With  the 
foot  at  a  right  angle  to  the  leg  the  incision  is  carried  down  to  the  bone, 

(  873) 


874 


OPERATIONS  ON  THE  FOOT  AND  ITS  JOINTS. 


beginning  a  finger's  breadth  above  the  tip  of  the  internal  malleolus,  and 
running  down  and  across  the  sole  toward  a  corresponding  incision  from 
the  external  malleolus.  With  the  foot  extended  the  ends  of  the  incision 
are  united  by  one  across  the  dorsum;  the  ankle-joint  is  then  opened, 
the  foot  disarticulated  backward,  the  calcaneum  sawed  through  from 
above,  and  close  behind  the  joint,  obliquely  downward  and  forward; 
the  malleoli  are  then  freed  and  sawed  off  straight  across  just  above  the 

Fig.  582. 


Stump  from  Pirogoff's  amputation.     (Hartley.) 

joint.  The  anterior  and  posterior  arteries  are  ligated,  the  heel-flap 
turned  forward,  the  bones  sutured  together  with  catgut,  and  the  dorsal 
flexor  tendons  sutured  to  the  front  of  the  heel-flap.  The  turns  of  the 
dressing  should  be  applied  from  behind  forward  to  hold  the  bone 
surfaces  in  contact. 

Sedillot,   Gunther,  and  Busch  suggest  making  the  plantar  incision 
and  the  division  of  the  calcaneum  more  obliquely  forward  and  down- 

Fig.  583. 


G'inther's  modification   of  Pirogoff's  amputation. 


ward  from  above  in  order  to  facilitate  coaptation  of  the  bone  stumps  in 
case  of  resistance  at  the  back  of  the  heel;  also  to  make  the  dorsal  incision 
more  obliquely  forward  and  to  saw  through  the  malleoli  in  a  corre- 
spondingly oblique  direction.     (Fig.  583.) 

Pasquier,  Le  Fort,  and  v.  Esmarch  saw  through  the  calcaneum  horizon- 
tally (Fig.  584),  beginning  the  plantar  incision  f  inch  below  the  tip  of 


AMPUTATION  AT  THE  ANKLE. 


875 


the   external  malleolus,  and  continuing  it  in  a  curve,  convex    forward, 
across  the  sole  to  end  U  inches  below  and  in  front  of  the  internal  mal- 


Fig.  584 


Le  Fort's  modification. 

Fig.  585. 


*s 


Fig.  5S6. 


S 


■^: 


Tauber's  incision  for  osteoplastic  amputation. 


leolus;  the  dorsal  incision  connects  these  points  in  a  curve,  convex  for- 
ward, over  Chopart's  joint,     v.  Bruns  saws  through  the  calcaneum  in  a 


876 


OPERATIONS  ON  THE  FOOT  AXD  ITS  .JOISTS. 


curve  concave  from  forward  backward  and  makes  the  cut  through  the 
malleoli  correspondingly  convex. 

Tauber  saws  through  the  calcaneum  vertically  in  the  anteroposterior 
direction  and  turns  up  the  inner  lateral  stump.  (Figs.  585  and  586.) 
Or  the  incision  may  be  reversed  and  the  outer  half  of  the  bone  used. 
Rasumowsky  modifies  this  somewhat  in  the  case  of  children,  in  order 
to  save  the  lower  epiphysis  of  the  tibia,  by  rounding  off  the  bone-flap  of 
the  calcaneum  and  turning  it  up  between  the  malleoli;  the  dorsal  flexor 
tendons  are  sutured  to  the  flap.  Ktister  in  one  instance  made  a  large 
plantar  and  small  dorsal  flap  and  fitted  the  entire  calcaneum  between 
the  malleoli. 

The  results  of  Pirogoff's  method  and  its  modification  are  usually 
excellent;  as  a  rule  the  bone  surfaces  unite  solidly  in  time — often  not 
until  after  the  patient  is  about — and  the  stump  becomes  resistant  and 
painless.  If  union  remains  insufficiently  firm,  the  surfaces  can  be 
freshened   up  and   sutured  or  nailed.     Osteoporosis  is  not  a  contra- 


Fig.  5S7. 


Perrin  and  Cham-el's  incision  for  subastragaloid  amputation.     (Roux  de  Brignoles.) 


indication  to  the  operation,  as  the  bones  become  more  solid  after  the  leg 
is  used.  In  children,  in  order  to  save  the  epiphyseal  line  of  the  tibia, 
the  operation  may  be  confined  to  removing  the  malleoli.  It  is  not 
advisable  in  general,  however,  to  scrape  out  and  leave  a  diseased 
calcaneum.  Although  a  prothesis  is  not  indispensable,  a  shoe  may- 
be worn  having  two  side  braces,  extending  to  the  knee,  attached  to  it, 
and  a  strip  of  spring  metal  in  the  front  part  of  the  shoe  to  give  elasticity. 
Subastragaloid  Amputation. — This  method  of  removing  all  of  the 
foot  except  the  astragalus  was  first  proposed  by  Lignerolles  (1839) 
and  Yelpeau,  performed  for  the  first  time  by  Traill  (cf.  Roux  de  Brig- 
noles) and  Textor  (1841),  and  by  the  French  generally  named  after 
Malgaigne.  The  ankle-joint  and  astragalus  have  to  be  intact,  and,  in 
spite  of  the  calcaneum  and  the  rest  of  the  foot  being  diseased,  sufficient 
healthy  material  for  the  flap  has  to  be  secured  from  the  back  part  of 
the  foot.  Chopart's  amputation  would,  therefore,  be  preferable  if  the 
calcaneum  were  healthy,  and  if  the  latter  condition  obtained;  but  if  the 


AMPl  TATION  AT  77/ A'  MEDIOTABSAL  JOINT. 


877 


hone  could  not  be  covered  in  properly,  the  author  would  prefer  Pirogoff's 
method.  This  operation,  which  is  employed  mainly  by  the  French,  is 
therefore  seldom  indicated. 

Textor  proceeds  as  in  Chopart's  amputation,  by  making  a  small 
dorsal  flap,  the  ends  of  which  join  a  transverse  plantar  incision  al  I  lie  level 
of  the  mediotarsal  joint.  To  facilitate  the  removal  of  the  calcaneum 
Gtinther  makes  a  horizontal  incision  backward  from  the  outer  angle 
of  the  incisions  which  corresponds  to  the  calcaneo-astragaloid  joint. 
Verneuil  makes  an  oval  incision,  Perrin  a  racquet  incision.  (Fig.  AST.) 
The  head  of  the  astragalus  is  sawed  off  if  sufficient  skin  cannot  be 
obtained.  Hancock  leaves  the  tuberosity  of  the  calcaneum  and  turns  it 
up  against  the  astragalus. 

Tripier  saves  the  lower  half  of  the  calcaneum.  (Fig.  588.)  Mal- 
gaigne  modifies  Tripier's  incision  by  making  a  small  outer  and  a  large 

Fig.  588. 


Tripier's  subastragaloid  amputation. 


inner  flap.  The  incision  begins  above  the  tuberosity  of  the  calcaneum, 
divides  the  tendo  Achillis,  curves  forward  under  the  external  malleolus 
to  the  middle  of  the  cuboid,  then  continues  over  the  dorsum  at  the 
anterior  margin  of  the  scaphoid  and  down  to  the  middle  of  the  sole,, 
and  finally  directly  backward  to  the  starting-point,  v.  Volkmann  makes 
a  large  inner  flap;  Farabeuf  large  inner  and  plantar  flaps. 


AMPUTATION  AT  THE  MEDIOTARSAL  JOINT. 


Chopart's  Amputation  (Figs.  589  and  590). — A  small  dorsal  flap  is 
made  by  means  of  an  incision  beginning  at  the  outer  border  of  the  foot, 
midway  between  the  base  of  the  fifth  metatarsal  and  the  external  malleo- 
lus, and  curving  forward  over  the  dorsum  and  then  backward  on  the  inner 
side  to  the  tuberosity  of  the  scaphoid.  The  flap  is  dissected  back  and 
the  tissues  on  the  dorsum  divided  transversely  down  to  the  bone  between 
the  ends  of  the  incision  with  the  foot  extended.     The  foot  is  then  dis- 


878 


OPERATIONS  ON  THE  FOOT  AND  ITS  JOINTS. 


Fig.  589. 


articulated  in  the  astragalonavicular  and  in  the  calcaneocuboid  joints. 

A  large  plantar  flap  is  then  made,  including  the  tendons  and  muscles. 

The  dorsal  and  internal  and  external  plantar 
arteries  are  ligated.  If  enough  skin  can  be 
obtained,  a  single  large  plantar  flap  is  prefer- 
able. 

To  prevent  the  retraction  and  eversion 
(equinovalgus  position)  of  the  heel  which  al- 
most alwavs  takes  place,  because  of  the  trac- 
tion of  the  tendo  Achillis  and  weighting  of 
«•  the  stump,  the  dorsal  flexor  tendons  can  be 
sutured  to  the  plantar  fascia  and  the  stump 
flexed  in  the  bandage.  As  soon  as  the  shoe 
can  be  wrorn,  the  sole  can  be  raised  in  front 
and  a  side  brace  fastened  to  the  shoe  to  pre- 
vent eversion.  If  the  retraction  of  the  heel 
becomes  troublesome,  the  tendo  Achillis 
should  be  divided.  The  operation  can  be 
modified  by  sawing  off  the  anterior  articular 
surfaces  of  the  astragalus  and  calcaneum 
(amputatio  talocalcaneo )  without  opening  the 
ankle-joint,  or  by  disarticulating  between  the 
scaphoid  and  cuneiforms  and  sawing  off  the 
Plantar  flap  in  chopart's  ampu-  cuboid  transversely.    This  preserves    the    in- 

cation  (0),  and  Listranc  s  amputa-  .  .  .,.*',.  .     l  ,-p,  ,.,, 

tion  (a).  sertion  of  the  tibialis  anticus.      Iwo  modih- 


Fig.  590. 


Stump  from  Chopart's  amputation,      a,  front  view;   6,  side  view.      (Stimson.) 


AMPUTATION  OF  SINGLE  METATARSALS  AND  TOES.       879 

cations  suggested  by  Helferich,  removal  of  the  front  of  the  calcaneum 
downward  and  backward  to  prevenl  pressure  of  the  front  margin  against 
the  soft  parts  and  decubitus,  and  arthrodesis  of  the  ankle-joint  possibly 
of  value  when  the  muscles  of  the  leg  are  paralyzed),  although  not 
necessary,  should  be  mentioned. 

AMPUTATION  THROUGH  THE  TARSOMETATARSAL  JOINTS. 

Lisfranc's  Amputation  (Fig.  589). — A  Large  plantar  and  a  small 
dorsal,  or  a  single  large  plantar  flap,  are  formed  by  means  of  a  dorsal 
and  a  plantar  incision  beginning  at  the  base  of  the  fifth  metatarsal  and 
ending  on  the  inner  side  of  the  foot  at  the  base  of  the  first  metatarsal. 
The  flaps  are  dissected  back  slightly,  the  front  of  the  foot  depressed, 
the  fifth  metatarsal  disarticulated,  then  the  third  and  fourth,  then  the 
first  and  second,  the  latter  while  the  foot  is  abducted.  The  dorsal 
tendons  are  sutured  to  the  plantar  faseia.  The  slight  equinovalgus 
position  resulting  may  be  overcome  by  raising  the  front  of  the  shoe. 

AMPUTATION  THROUGH  THE  METATARSALS. 

Sharp's  Amputation. — The  operation  is  analogous  to  Lisfranc's 
amputation,  but  is  preferable  to  it  as  it  gives  a  longer  support.  It 
is  rarely  indicated  except  for  injuries  or  frostbite  of  the  toes  with 
involvement  of  part  of  the  skin   of  the  dorsum. 

AMPUTATION  OF   SINGLE  METATARSALS  AND  TOES 

Amputation  of  a  single  toe  with  its  metatarsal  is  rarely  indicated  and 
is  a  questionable  procedure  on  account  of  the  resulting  functional  dis- 
turbance. This  applies  particularly  to  the  first  toe.  Its  function  may  be 
assumed  by  the  second  toe,  but  the  foot  is  very  liable  to  become  abducted 
and  everted  and  make  walking  difficult.  If  a  flat-foot  position  already 
exists,  its  removal  is  less  troublesome.  Amputation  of  one,  or  even 
two,  of  the  middle  metatarsals,  or  of  the  fifth,  is  even  less  serious.  If 
the  two  inner  metatarsals  or  three  of  the  others  have  to  be  sacrificed, 
it  is  better  to  amputate  all  transversely  through  the  bones,  or  at 
Lisfranc's  joint. 

The  first  or  fifth  metatarsal  and  its  toe  are  usually  amputated  through 
an  oval  (racquet)  incision,  the  longitudinal  incision  being  made  midway 
between  the  dorsum  and  side  of  the  toe  to  prevent  pressure  upon  the 
scar,  analogous  to  the  method  for  the  thumb.  The  oval  incision  is 
also  the  best  for  one  or  more  of  the  other  metatarsals.  In  removing 
two  metatarsals  care  should  be  exercised  to  have  sufficient  skin  on  the 
dorsum,  also  making  a  transverse  incision  over  the  tarsometatarsal 
joints  to  gain  access  to  the  latter.  When  the  fourth  and  fifth  are  con- 
cerned the  longitudinal  dorsal  incision  is  made  over  the  fourth  and 
curved  out  sharply  or  gradually  at  the  base  of  the  metatarsus  to  reach 
the  joint  of  the  fifth. 


880  OPERATIONS  OX  THE  FOOT  AND  ITS  JOINTS. 

AMPUTATION  OF  THE  TOES. 

Amputation  of  all  the  toes  in  the  metatarsophalangeal  joints  can  be 
done  by  the  small  dorsal  and  large  plantar  flap  method.  Two  lateral 
longitudinal  incisions  are  carried  forward  on  the  first  and  fifth  toes 
to  the  level  of  the  commissures.  The  toes  are  exarticulated  through  a 
transverse  dorsal  incision  at  the  level  of  the  commissures  and  a  large 
plantar  flap  formed. 

Single  toes  can  be  amputated  by  the  oval  method.  In  amputating 
the  large  toe  a  flap  taken  from  the  inner  and  plantar  surfaces  is  preferable 
in  order  to  bring  the  scar  between  the  first  and  second  toes,  and  not  on 
the  dorsum  or  front,  where  it  is  exposed  to  pressure. 

For  amputation  or  exarticulation  of  the  phalanges  a  large  plantar 
flap  is  preferable. 

RESECTION  OF  THE  TIBIOTARSAL  JOINT. 

Typica.  resection  of  the  ankle-joint  was  first  performed  by  Moreau 
in  1792,  but  was  not  generally  adopted  until  after  B.  v.  Langenbeck 
hail  demonstrated  its  value  in  the  Danish  war  of  1864. 

Langenbeck's  Method. — Langenbeck's  method  of  making  two  lat- 
eral longitudinal  incisions  is  similar  to  that  of  Moreau  and  Bonrgery's 
modification  of  the  same:  the  outer  incision,  2  to  3  inches  long,  is  car- 
ried along  the  posterior  border  of  the  fibula  to  a  finger's  breadth  below 
the  tip  of  the  malleolus.  Hiiter  adds  a  second  incision  extending  h  inch 
upward  and  forward  from  the  lower  end  of  the  first  incision  along  the 
front  border  of  the  fibula.  The  periosteum  is  lifted  off  from  the  bone, 
the  joint  between  the  tibia  and  fibula  opened,  the  fibula  sawed  through 
with  a  chain  or  keyhole  saw,  and  the  lower  portion  removed.  The 
incision  on  the  inner  side  is  made  in  the  same  manner,  the  tibia  being 
sawed  off  at  the  same  level  as  the  fibula  after  dividing  the  deltoid 
ligament  and  everting  the  foot.  The  foot  is  then  disarticulated  outward 
and  the  astragalus  sawed  through  or  removed  as  indicated.  For  re- 
section of  the  lower  end  of  the  tibia  alone  v.  Langenbeck  makes  the 
usual  longitudinal  incision,  and  adds  a  curved  incision,  convex  down- 
ward,  encircling  the  tip  of  the  malleolus  (anchor  incision). 

Hiiter  used  this  anchor  incision  for  total  resection. 

The  subsequent  functional  result  depends  upon  the  stability  of  the 
new  joint  and  the  position  of  the  foot.  A  firm  nearthrosis  with  slight 
mobility  is  possibly  most  desirable,  yet  complete  ankylosis  is  nearly 
as  useful,  for  the  foot-joints  acquire  a  compensatory  mobility  and 
restore  the  elasticity  of  the  gait  to  a  certain  extent.  An  unstable  near- 
throsis or  actual  loose-joint  renders  the  foot  more  or  less  useless;  hence 
the  importance  of  not  attempting  to  restore  any  great  amount  of  mobility 
by  methodical  exercises.  After  subperiosteal  resection  for  trauma  the 
new  bone  formation  is  generally  abundant  and  consolidation  rapid. 
On  the  other  hand,  resection  for  tuberculosis  is  more  apt  to  give  a 
flabby  nearthrosis,  although  the  healing  process  often  advances  slowly 


RESECTION  <>F  THE  TIBIOTARSAL  JOINT. 


881 


but  steadily,  and  many  a  loose  joint  finally  acquires  the  necessary 
stability,  provided  that  it  is  protected  properly  and  for  a  sufficient 
length  of  time  by  a  good  fixation  splint. 

The  position  of  the  foot  is  equally  important.  It  should  be  at  a 
right  angle  to  the  le<r  and  midway  between  eversion  and  inversion 
and  abduction  and  adduction.  This  rule  applies  to  all  resections  of 
the  foot,  after  which  the  patient  is  to  bear  the  weight  on  the  sole  of 
the  foot.  Any  faulty  position  entailed  by  failure  to  carry  out  this  rule 
renders  the  foot  more  or  less  useless  and  often  necessitates  forcible 
correction  later  or  secondary  resection. 


Fig.  591. 


Fig.  592. 


Kiinig's  incision  for  resection  of 
•   the  ankle-joint. 


a.  Interna!  malleolus  chiselled  off  and  retracted,   b.  Chisel  to 
remove  articular  surface  of  tibia,   c.  Astragalus. 


For  injuries  of  the  joint  Langenbeck's  method  meets  all  requirements. 
On  the  other  hand,  for  tuberculosis  of  the  joint  it  is  quite  inadequate, 
for  in  cases  of  partial  resection  of  the  bones  of  the  joint  thorough  inspec- 
tion and  complete  removal  of  the  diseased  synovialis  is  impossible,  and 
in  total  resection,  removal  of  the  posterior  portions  of  the  capsule  is 
very  difficult.  Too  much  bone  has  to  be  sacrificed  to  reach  the  back 
of  the  joint  to  insure  proper  consolidation.  Since  the  tuberculous 
nature  of  chronic  joint  inflammations  has  been  known  and  the  necessity 
of  radical  incision  of  the  entire  synovialis  appreciated,  a  considerable 
number  of  resection  methods  and  modifications  have  arisen  of  which 
only  the  most  important  will  be  considered. 

For  tuberculosis  of  the  joint  the  following  methods  are  preferable: 
Konig's  Method  (Fig.  501). — Two  lateral  longitudinal  incisions  are 
made  somewhat  in  front,  the  inner  beginning  1^  inches  above  the  joint 
Vol.  III.— 56 


882 


OPERATIONS  ON  THE  FOOT  AND  ITS  JOINTS. 


and  running  along  the  anterior  border  of  the  internal  malleolus  to  the 
astragalonavicular  joint,  the  outer  parallel  to  it  and  ending  at  the  sinus 
tarsi.  The  bridge  of  tissues  between  them  in  front  is  lifted  off  and  the 
joint  exposed.  The  interal  malleolus  is  chiselled  off  obliquely,  still 
attached  to  the  ligaments  (Fig.  592),  and  turned  down;  the  lower  end  of 
the  tibia  is  then  chiselled  off  squarely  and  the  joint  exposed.  The 
outer  malleolus  is  chipped  off  in  the  same  way  and  the  fibula  chiselled 
squarely  off.  By  retracting  the  edges  of  the  wound  and  pulling  on  the 
foot  all  parts  of  the  synovialis  are  accessible.     The  tips  of  the  malleoli 


Fig.  593. 


Ollier's 


resection  of  ankle-joint. 


are  then  replaced  and  held  in  place  by  the  dressing.  To  expose  the 
posterior  part  of  the  joint,  v.  Bruns  adds  two  longitudinal  incisions  at 
the  sides  of  the  tendo  Achillis. 

Ollier's  Method  (Fig.  593,  a,  b). — The  outer  incision  begins  2  inches 
above  the  joint  in  front  of  the  malleolus  and  runs  downward  to  the 
cuboid  in  a  line  passing  between  the  fourth  and  fifth  metatarsals.  From 
this  a  second  incision  is  made  \\  inches  downward,  beginning  a  finger's 
breadth  in  front  of  the  tip  of  the  malleolus.  The  tibiotarsal  and  cal- 
caneo-astragaloid  joints  are  opened  after  retracting  the  extensor  brevis 
outward.  The  inner  incision  curves  around  in  front  of  the  internal 
malleolus  with  an  arm  extending  forward.     The  astragalus  is  freed 


>< 


RESECTION  OF  THE  TIBIOTABSAL  JOINT. 


883 


from  the  fibula  and  calcaneum,  the  astragalonavicular  joint  opened, 

and  the  interosseous  ligaments  divided;  the  deltoid  ligament  is  divided 
and  the  astragalus  exposed  and  extracted. 

Vogt's  Method.  -P.  Vogt  recommends  to  always  remove  the  astrag- 
alus. Like  Oilier  he  makes  a  long  anterior  and  a  transverse  lateral 
incision:  the  anterior  incision,  in  adults  4  inches  long,  passes  down 
over  the  ankle-joint  from  between  the  tibia  and  fibula  to  Chopart's 
joint.  The  tendons  of  the  extensor  longus  digitorum  are  drawn  to 
the  inner  side,  the  extensor  brevis  is  incised  and  drawn  outward.  The 
capsule  is  then  divided  in  its  entire  extent,  the  neck  and  head  of  the 
astragalus  exposed,  and  the  astragalonavicular  ligament  divided.    After 


Fig.  594. 


Trillion  of  peronei. 
External  malleolus. 


Caput  tal 

Trochlearis. 
Kocher's   resection. 


Istragalonavicular 

joint. 

Tnnloii  of  peronei. 
Internal  malleolus. 


thus  exposing  the  front  and  outer  part  of  the  astragalus,  the  transverse 
incision  is  made  outward  to  below  the  tip  of  the  external  malleolus. 
The  soft  parts  are  incised  in  layers  down  to  the  astragalus,  the  foot  is 
strongly  inverted,  the  external  lateral  ligament  divided  and  the  ligaments 
in  the  sinus  tarsi  divided  with  the  knife  or  chisel.  The  head  of  the 
astragalus  is  seized  with  the  bone  forceps,  and  the  bone  is  twisted 
outward  so  that  the  ligaments  on  the  inner  side  can  be  lifted  off  with 
a  broad  chisel.  After  dividing  the  ligaments  behind  and  removing  the 
astragalus,  the  entire  joint  can  be  inspected. 

Kocher's  Method. — Kocher,  Albanese,  and  Lauenstein  use  an  outer 
curved  incision  (Fig.  504),  beginning  4  to  5  inches  above  the  tip  of 
the  malleolus,  running  down  behind  the  fibula  and  forward  under  the 


884  OPERATIONS  ON  THE  FOOT  AND  ITS  JOINTS. 

malleolus  at  the  level  of  the  calcaneo-astragaloid  joint  to  the  end  at  the 
peroneus  tertius.  The  lesser  saphenous  vein  and  external  saphenous 
nerve  are  behind  the  incision.  The  sheaths  of  the  peronei  are  exposed 
and  opened  lengthwise.  The  periosteum  is  lifted  from  the  outer  and 
under  surface  of  the  malleolus  and  the  joint  opened  in  front.  The 
capsule  is  dissected  off  from  the  external  surface  of  the  astragalus  to 
the  fibula  and  the  ligaments  divided;  the  capsule  and  periosteum  are 
separated  from  the  tibia  in  front  and  behind,  the  tendon-sheaths  of  the 
peronei  being  left  attached  to  the  periosteum;  the  foot  is  dislocated 
inward.     The  internal  lateral  ligament  is  not  divided  unless  necessary. 

Anterior  Transverse  Incision. — Heyfelder,  Sediliot,  Hiiter,  and  many 
others  recommend  an  anterior  transverse  incision  between  the  malleoli. 
The  anterior  tibial  artery  is  double  ligated,  the  peroneal  nerve  and 
tendons  are  transfixed  with  catgut  before  being  divided,  in  order  to  be 
sutured  later;  the  joint  is  then  opened  transversely. 

If  the  incision  is  curved  forward  to  form  an  anterior  flap,  Lisfranc's 
joint  is  also  exposed,  and  if  necessary  v.  Bruns'  tibiocalcaneal  resec- 
tion can  be  made.  (See  page  886.)  With  this  anterior  flap  incision 
we  have  kept  the  wound  open  for  a  long  while  and  still  preserved  some 
extensor  power  of  the  toes. 

To  open  the  joint  from  behind  or  below  (posterior  tarsectomy), 
C.  Textor  makes  a  posterior  transverse  incision  dividing  the  tendo 
Achillis.  F.  Busch  makes  an  inferior  stirrup-shaped  transverse  incision: 
Beginning  at  the  external  malleolus  the  incision  crosses  the  sole,  curving 
slightly  backward,  and  ends  at  the  internal  malleolus.  The  tendons, 
vessels,  and  nerves  are  lifted  en  masse  out  of  the  grooves  behind  the 
malleoli  and  drawn  upward.  The  calcaneum  is  divided  transversely 
and  obliquely  upward  and  backward  to  the  posterior  margin  of  the 
calcaneo-astragaloid  joint,  the  posterior  part  of  the  capsule  incised,  and 
the  joint  exposed  by  separating  the  fragments.  The  latter  are  sutured 
together  with  silver  wire  later.  Ssabanejew  makes  a  posterior  triangu- 
lar flap  with  the  angles  of  the  base  at  the  malleoli  and  the  apex  at  the 
insertion  of  the  tendo  Achillis.  The  tuberosity  of  the  calcaneum  is 
sawed  off  and  turned  up  together  with  the  soft  parts  and  later  fastened 
back  in  place  with  ivory  pegs.  Bogdanik's  modification  is  similar: 
The  incision  connecting  the  tip  of  the  malleoli  crosses  the  heel  ^  inch 
above  the  sole,  the  calcaneum  is  sawed  through  transversely  up  to  the 
calcaneo-astragaloid  joint,  the  contents  of  the  joint  or  the  astragalus 
are  removed,  and  the  calcaneum  sutured.  All  three  methods  have  the 
disadvantage  of  possible  malunion  in  the  event  of  suppuration. 

RESECTION  AND  EXCISION  OF  THE  CALCANEUM. 

Rigaud  makes  a  horizontal  U-shaped  incision  running  forward  at 
both  sides  of  the  bone  and  dividing  the  tendo  Achillis  at  its  insertion. 
The  plantar  flap  is  dissected  off  together  with  the  periosteum.  The 
upper  flap  includes  the  periosteum,  the  tendon-sheaths  at  the  sides 
behind  the  malleoli,  and  the  insertion  of  the  tendo  Achillis.   After  opening 


RESECTION  AND  EXCISION  OF  TILE  ASTRAGALUS.  885 

the  calcaneocuboid  and  calcaneo-astragaloid  joints,  the  ligaments  in 
the  sinus  tarsi  can  be  divided  and  the  bones  extracted.  It  would  be 
preferable  when  possible  to  preserve  the  connection  between  the 
tendo  Achillis  and  periosteum  on  the  plantar  surface  of  the  calcaneum. 

Oilier  makes  an  external  angular  incision,  the  vertical  limb  beginning 
1  inch  above  the  level  of  the  tip  of  the  external  malleolus  at  the  outer 
border  of  the  tendo  Achillis  and  running  down  under  the  heel,  the  other 
arm  running  from  this  point  along  the  outer  border  of  the  foot  to  the 
base  of  the  fifth  metatarsal  and  then  turning  slightly  upward.  The 
outer  Hap  is  lifted  subperiosteally  from  the  bone  leaving  the  tendo 
Achillis  still  attached  to  the  periosteum  of  the  plantar  surface.  The 
inner  flap  can  be  peeled  oil'  in  the  same  way,  and  the  skin,  together  with 
the  tendo  Achillis  and  periosteum,  drawn  forward  and  inward.  The 
calcaneocuboid  joint  can  then  be  opened,  and  with  a  thin  bladed  knife, 
the  calcaneo-astragaloid  joint.  While  the  bone  is  pulled  downward 
with  the  bone  forceps  the  interosseous  ligaments  are  divided  and  the 
separation  of  the  soft  parts  on  the  inner  surface  completed.  In  the 
existence  of  marked  swelling  the  last  step  is  facilitated  by  an  incision 
on  the  inner  side. 

Complete  loss  of  the  calcaneum  disables  the  foot  considerably,  although 
not  entirely;  the  arch  of  the  foot  is  destroyed;  eversion  and  inversion, 
and  more  especially  plantar  flexion,  are  impaired;  the  elasticity  of  the 
foot  is  wanting,  so  that  the  gait  is  heavy.  This  can  be  improved  some- 
what by  a  support  in  the  heel  of  the  shoe.  As  a  rule,  the  results  are 
much  better  if  the  periosteum  can  be  preserved,  for  from  this  a  partial 
regeneration  of  the  bone  takes  place.  This  is  particularly  true  in 
youthful  individuals,  and  especially  after  osteomyelitic  necrosis.  The 
value  of  preserving  the  tendo  Achillis  and  the  posterior  epiphysis  has 
been  mentioned.  It  is  equally  important  to  preserve  the  anterior 
process,  in  order  to  avoid  opening  the  anterior  joint  of  the  calcaneum, 
if  possible. 


RESECTION  AND  EXCISION  OF  THE  ASTRAGALUS. 

The  astragalus  is  excised  preferably  through  an  external  incision,  as 
made  by  Vogt  and  Oilier.     (See  above.) 

Posterior  Tarsectomy. 

If  the  front  part  of  the  foot  is  sound,  the  posterior  part  of  the  tarsus 
can  be  removed  with  or  without  the  tibiotarsal  articulation.  To  remove 
the  astragalus  and  calcaneum,  Oilier  first  excises  the  calcaneum  and 
then  the  astragalus.  The  anterior  inner  or  outer  incision  can  be  added 
to  gain  access  to  the  tibiotarsal  joint.  The  malleoli  are  preserved  if 
possible,  and  the  scaphoid  is  inserted  between  them.  The  posterior  or 
inferior  transverse  incision  of  Busch,  Hahn,  or  Bogdanik  may  be  used 
instead. 


886 


OPERATIONS  OX  THE  FOOT  AND  ITS  JOISTS. 


v.  Bruns'  Tibiocalcaneal  Resection. — v.  Brims  showed  that  it  is 
often  possible  and  of  value  to  preserve  the  lower  part  of  the  caleaneum. 
He  removes  the  astragalus  and  the  articular  surfaces  of  the  tibia,  fibula, 
and  caleaneum,  and  obtains  bony  ankylosis  between  the  calcaneal 
plate  and  lower  end  of  the  tibia  and  fibula.  For  this  an  anterior  curved 
incision  is  best.  v.  Bruns  occasionally  uses  a  posterior  transverse  incision 
passing  through  the  tendo  Achillis  or  lateral  incisions. 

Wladimiroff-Mikulicz  Osteoplastic  Resection. — Wladimiroff  and 
Mikulicz'  osteoplastic  resection  is  performed  through  a  transverse  incision 
in  the  sole  connected  at  either  side  with  a  horizontal  incision  above  the 
heel  by  two  oblique  cuts.    (Fig.  595.)    The  plantar  incision  begins  at  the 


Fig.  595. 


Wludimiroff-Mikulicz'   osteoplastic  resection,      (v.  Bergmann.) 


inner  side  in  front  of  the  tuberosity  of  the  scaphoid,  and  ends  on  the  outer 
side  of  the  foot  behind  the  base  of  the  fifth  metatarsal.  The  horizontal 
portion  divides  the  tendo.  Achillis.  The  foot  is  flexed  strongly,  the 
tibiotarsal  joint  opened  from  behind,  and  the  astragalus  and  caleaneum 
removed  with  the  soft  parts  of  the  heel.  The  articular  surface  of 
the  tibia  is  sawed  off  with  the  malleoli;  also  the  surfaces  of  the  cuboid 
and  scaphoid.  The  posterior  tibial  and  external  and  internal  plantar 
arteries  are  ligated  and  the  sawn  surfaces  brought  together  with  the 
foot  in  the  equinus  position.  The  soft  parts  are  sutured  together  with 
catgut.  Bone  sutures  are  not  indispensable.  The  limb  is  usually 
|  inch  longer  than  the  other  after  operation.  The  various  modifications 
of  the  operation  have  been  published  by  Lossen  and  Kummer. 

The  results  of  the  operation  are  generally  good.  Of  73  cases  col- 
lected by  Kohlhaas  in  1891,  56  could  stand  and  walk  well.  In  general 
the  operation  is  only  indicated  when  the  soft  parts  are  markedly  dis- 
eased in  addition  to  the  process  in  the  bones.  If  the  soft  parts  are 
intact,  posterior  tarsectomy  is  preferable.  The  method  has  been  used 
to  lengthen  a  shortened  limb,  as  in  paralytic  talipes  equinus  and  atrophy 
of  the  leg.  (v.  Bruns.)  Lengthening  of  an  inch  or  more  is  possible  by 
the  removal  of  very  little  bone. 

Anterior  Tarsectomy. 

The  term  anterior  tarsectomy  is  applied  to  transverse  resection  of  the 
anterior   tarsal   bones,  and   finally  of   part  of  the  metatarsus.     Single 


RESECTION  OF  THE  JOINTS  OF  THE  TOES.  887 

tarsal  hones  may  be  removed  without  greatly  impairing  the  function 
of  the  foot,  but  the  operation  is  rarely  indicated,  as  usually  more  than 
one  hone  or  joint  is  affected. 

Transverse  resection  of  the  tarsus  can  be  performed  through  two 
lateral  longitudinal  incisions.  The  tissues  are  lifted  off  on  the  dorsum 
ami  in  the  sole,  and  the  portion  of  the  tarsus  and  the  metatarsus  to  he 
removed  can  he  sawed  off  transversely.  The  bones  are  more  accessible 
through  a  long  curved  dorsal  flap  incision.  After  the  resection  is  com- 
pleted the  wound  is  packed  for  a  few  days  or  closed  primarily.  The 
sawn  surfaces  are  apposed  to  favor  bony  union.  The  latter  is  better 
insured  by  resecting  with  saw  or  chisel  in  sound  bone  than  through 
the  joints.  The  tendons  are  sutured,  and  the  wound  closed  partially 
and  drained  at  the  sides. 

Witzel's  suggestion  to  employ  the  incision  for  Chopart's  amputation 
and  preserve  the  toes  can  only  be  considered  if  Chopart's  joint  and  the 
toes  and  plantar  tissues  are  intact.  Witzel  makes  a  transverse  incision 
from  the  tuberosity  of  the  scaphoid  over  the  dorsum  to  a  finger's  breadth 
above  the  base  of  the  fifth  metatarsal,  and  from  either  end  two  longi- 
tudinal incisions  toward  the  toes,  connecting  the  anterior  ends  of  the 
latter  by  another  transverse  incision  over  the  dorsum,  thus  removing 
a  quadrilateral  portion  of  the  skin  with  the  bones.  Transverse  resection 
of  the  diseased  bones  and  tissues  follows.  The  stumps  are  approx- 
imated and  are  supposed  to  heal  together  by  fibrous  union,  giving  a 
certain  amount  of  elasticity  to  the  foot. 

RESECTION  OF  THE  METATARSAL  BONES. 

Resection  of  one  or  more  metatarsals  in  continuity  is  seldom  indi- 
cated. Disease  spreading  to  the  line  of  Lisfranc's  joint  necessitates 
transverse  tarsectomy  or  tarsometatarsal  resection.  In  osteomyelitis 
or  traumatic  necrosis  of  single  metatarsals  the  bone  may  be  removed 
as  the  growth  of  bone  from  the  periosteum  and  the  epiphyses  may 
be  adequate,  especially  in  young  subjects.  Otherwise  amputation  is 
preferable,  as  the  cicatricial  contraction  resulting  from  the  necrosis 
produces  a  troublesome  deformity.  Resection  can  be  performed 
through  a  longitudinal  incision  at  the  side  of  the  extensor  tendon, 
preserving  the  epiphysis  and  joints  if  possible.  In  the  first  metatarsal 
the  epiphysis  is  proximal,  in  the  others  distal. 

RESECTION  OF  THE  JOINTS  OF  THE  TOES. 

Resection  of  the  metatarsophalangeal  joint  applies  almost  exclusively 
to  the  great  toe.  (See  page  854.)  Resection  of  the  interphalangeal 
joints  is  analogous  to  the  operations  on  the  fingers,  and  is  only  indi- 
cated for  contractures.  As  the  loss  of  a  toe  is  of  slight  importance,  it  is 
unprofitable  to  preserve  a  digit  that  is  rendered  useless  or  troublesome 
bv  deviation  or  contracture. 


INDEX 


ABRACHIA,  117 
Abscess  of  axilla.  80 

of  muscles  of  upper  arm,  144 
of  popliteal  space,  654 
treatment  of,  654 
Accident  and  judgment,  263 
Acromegaly  of  hand,  351 
Acromial  bursitis,   7S 
Adenitis  of  axilla,  80 

tuberculous,  80 
cubital,    143 

syphilitic,   143 
inguinal,  522 

suppurative,  522 
syphilitic,  522 
Ainhum,  774 

Aluminum  acetate  for  ulcers  of  leg,  686 
Amelia,   117 

Amputation  of  ankle,  873 
Pirogoff's,  873 
Syme's,  873 
of  arm,  spontaneous,  117 

upper,  158 
at  elbow-joint,  226 
of  fingers,  378,  379 

phalanges  of,  379 
of  forearm,  259 
of  hand,  377 
of  hip-joint,  527 
Eranke,  528 
haemostasia  in,  527 

Braun's  method  of,  527 
Biingner's  method  of,  527 
Davy's  method  of,  527 
v.    Esmarch's    method    of, 

527 
Larrey's  method  of,  527 
McBurney's  method  of.  527 
Riedel's  method  of,  527 
Rose's  method  of,  527 
Schonborn's  method  of,  527 
Trendelenburg's  method  of. 
527 
mortality  of,  529 
Quenu's,  528 
Rose's,  527 
subperiosteal,  528 

of  Vetch  and  Ravaton,  528 
of  v.  Volkmann,  528 
transfixion  method,   527 
Yerneuil's,    527 
at  knee,  713 
of  leg,  713 


Amputation,  Malgaigne's,  876 

at   mediotarsal  joint,  Chopart's,  877 
of  metacarpals,  377 
of  metatarsals,  879 
Pirogoff's  osteoplastic,  873 
of  shoulder,    108 

interscapulothoracic,   112 
of  single  metatarsals  and  toes,  879 
subastragaloid,  876 
Syme's,  873 
Textor's,  877 
of  thigh,  562 

Abrashanow's,  564 
Buchanan's,   563 
Cardan's,  563 
Djelitzyn's,  563 
Farabeuf's,   562 
Gritti's,  562 
Jacobson's,  564 
Spence's,  562 
Ssabanejeff's,  563 
through  metatarsals,  879 
Sharp's,  879 
tarsometatarsal  joints,  879 
Lisfranc's,  879 
of  toes,   880 
Aneurism  of  axilla,  81 

arteriovenous,  82 
symptoms  of,  81 
treatment  of,  82 
of  brachial  artery,  145 
cirsoid,  of  hand,  36S 
of  femoral  artery,  549 
of  foot,  862 

diagnosis  of,  862 
treatment  of,  862 
of  humerus,  151 
of  leg,  689 

symptoms  of,   689 
treatment  of,  6S9 
popliteal,  654 

symptoms  of,  655 
treatment  of,  655 

by  extirpation,   656 
by  ligation,  656 

and  excision,  656 
by  Matas'    arteriorrhaphv, 
'657 
of  thigh,  549 

treatment  of,  549 
Angioma  of  foot,  870 

of  muscles  of  upper  arm,  144 
Ankle,  diseases  of,  773 

(S89) 


890 


INDEX. 


Ankle,  inflammations  of,  acute,  773 
treatment  of,  773 
chronic,  773 
-joint,  amputation  of,  873 
anatomy  of,  717 
inflammations  of,  acute,  781 

treatment  of,  782 
injuries  of,  728 

complicated,  766 

treatment  of,  767 
compound,  766 

treatment  of,  767 
physiology  of,  717 
resection  of,  880 

by  anterior   transverse   in- 
cision, 884 
sprains  of,  728 

treatment  of,  728 
synovitis  of,  acute,  781 

gonorrheal,   782 

hemorrhagic,  782 

in   infectious   diseases, 

782 
serous,    781 
suppurative,  782 
treatment  of,  782 
tabetic  disease  of,  869 
Charcot,   869 
skin  of,  tuberculosis  of,  774 
Ankylosis  of  hand,  356 
of  hip-joint,  501 

diagnosis  of,  504 
symptoms  of,  503 
treatment  of,  505 
ambulant,  505 
forcible  reduction,  505 
Hoffa's  apparatus,  507 
Lorenz'  apparatus,  506 
operative,  508 
of  knee-joint,  626 

prognosis  of,  627 
treatment  of,  627 
of  shoulder-joint,  98 
treatment  of,  99 
Arm.  erysipelas  of,  143 

malignant  oedema  of,  143 
phlegmonous  processes  of,  143 
upper,  amputation  of,  158 
evulsion  of,  141 
injuries  of,  gunshot,  139 
diagnosis  of,  140 
treatment  of,  140 
malformations  of,   117 
muscles  of,  abscess  of,  144 
angioma  of,  144 
diseases  of,  144 
gumma  of,  144 
hernia  of,  119 
injuries  of,   118 
ossification  of,  144 
rupture  of,  119 

diagnosis  of,  120 
etiology  of,  119 
prognosis  of,  120 
symptoms  of,  120 
treatment  of,  120 


Arm,  upper  muscles  of,  wounds  of,   118 
nerves  of,  diseases  of,  145 
injuries  of  122 

course  of,  122 
prognosis  of,  122 
symptoms  of,  122 
treatment  of,   123 
neuroma  of,  145 

diagnosis  of,  146 
prognosis  of,  146 
treatment  of,  146 
operations  on,  156 
prothesis  for,  159 
shaft  of,  resection  of,  157 
skin  of,  neoplasms  of,  144 

tumors  of,  144 
soft  parts  of,  diseases  of,  143 

injuries  of,  118 
syphilitic  myositis  of,   144 
vessels  of,  diseases  of,  145 
injuries  of,  121 

diagnosis  of,  121 
prognosis  of,  121 
subcutaneous,  121 
treatment  of,   121 
wounds  of,  severe  lacerated,  141 
Arteriorrhaphy,   Matas',  657 
Arteriovenous  aneurisms  of  axilla,  82 
Arteries  at  elbow-joint,  ligation  of,  227 

of  leg,  ligation  of,  715 
Artery,  axillary,  injuries  of,  20 
ligation  of,  105 
brachial,   aneurism  of,    145 
injuries  of,  121 
ligation  of,  156 
cubital,  ligation  of,  227 
femoral,  aneurism  of,  549 
injuries  of,  532 
ligation  of,  559 
radial,  ligation  of,  259 
at  wrist,  375 
subclavian,  injuries  of,  20 

ligation  of,  22 
tibial,  anterior,  ligation  of,  715 
posterior,  ligation  of,  716 
ulnar,  ligation  of,  259 
at  wrist,  375 
Arthritis  deformans,  785 
coxa  vara  in,  518 
of  elbow-joint,  212 
of  foot,  treatment  of,  785 
of  hand,  348 

neuropathic,  350 
of  hip-joint,  494 

diagnosis  of,  497 
etiology  of,  497 
pathological     anatomy    of, 

495 
prognosis  of,  499 
symptoms  of,  497 
treatment  of,  499 
of  knee-joint,  chronic,  619 
Arthropathy  of  Charcot  of  knee-joint,  625 
Astragalectomy  for  club-foot,  822 
Astragalus,  dislocation  of,  total,  762 
diagnosis  of,  763 


INDEX. 


X<)1 


Astragalus,  dislocation  of,   total,   treat- 
ment of,  7t>l 

excision    of,    885 

fractures  of,  7  1 1 

diagnosis  of,  7  15 
i  real  menl  of,  746 

resection  of,  885 

Atheroma  of  thigh,  557 
Avicenna's  method  for  forward  disloca- 
tions of  shoulder,  68 
Axilla,  abscess  of,  80 

adenitis  of,  80 

tuberculous,  SO 
aneurisms  of,  81 

arteriovenous,  82 
symptoms  of,  81 
treat  menl  of,  82 
eczema  of,  80 
hsematoma  <>f,  22 
inflammatory  processes  of,  80 

treatment  of,  81 
neoplasms  of,   83 
tumors  of,  83 
Axillary,  abscesses,  80 
adenitis,  80 
artery,  injuries  of,  20 

ligation  of,  105 
dislocations  of  shoulder,  til 
prognosis  of,  65 
symptoms  of,  64 
treatment  of,  65 
eczema,  80 
furuncle,  80 
hydroadenitis,  80 
nerves  of  shoulder,  injuries  of,  23 
vein,  injuries  of,  23 


BARDENHEUER'S  extension  for  dis- 
located clavicle,  39 

for  fractured  clavicle,  32 
for  supracondyloid   fracture   of 
humerus,  175 
treatment  of  Pott's  fracture,  740 
Baum's  method  for  dislocated  clavicle,  37 
Baynton's  method  for  ulcers  of  leg,  687 
Beck's  coaptation  splint,  307 
Beelv's  apparatus  for  hollow  foot,  850 
plaster-of-Paris  splint  for  leg,  678 
splint  for  club-foot,  814 

for  fractured  humerus,  57 
Biceps,  rupture,  of,  119 

tendon,  dislocation  of,   19 
ossification  of,  242 
Billroth's  apparatus  for  loose   shoulder, 

102 
Bone  filling,  v.  Mosetisi's,  702 

suture  of  Hennequin  and  Wille,  136 
methods  of,  for  humerus,   137 
Bones,  carpal,  fracture  of,  300 
treatment  of,  301 
of  finger,  diseases  of,  346 
of  foot,  inflammation  of,  781 
tuberculosis  of,  785 
diagnosis  of,  788 
frequency  of,  786 


Bones  of  foot,  tuberculosis  of,  symptoms 
of,  787 
i  reatmenl  of,  790 
of  forearm,  fractures  of,  2  16 
upper  end  of,  L89 
injuries  of,  247 
malformai  ions  of,  243 

osteomyelil  is    of,    2.">.j 

symptoms  of,  255 

treatment    of,  256 
tumors  of,  257 
of  hand,  acromegaly  of,  351 

diseases  of,   346 
inflammation   of,   acute,  346 
chronic,   348 
of  leg,  fracture  of  shaft  of,  671 
syphilis  of,  705 
tuberculosis  of,  703 

treatment  of,  705 
tumors  of,  710 
of  tarsus,  suppuration  of,  783 
of  thigh,  diseases  of,  551 

injuries  of,  535 
of  toes,  acute  inflammation  of,  783 
treatment  of,  784 
Bowlegs,   645 

Braatz'  epaulette  dressing,  31 
Brachial  artery,  aneurism  of,  145 
injuries  of,  121 

diagnosis  of,  121 
prognosis  of,  121 
subcutaneous,   121 
treatment  of,  121 
ligation  of,  156 
neuritis,  145 
Bruck's  air  cushion,  694 
v.  Bruns'  method  for  forward  dislocation 
of  shoulder,  68 
tibiocalcaneal  resection,  886 
Bubo,   indolent,  of    syphilis   of  inguinal 

gland,  522 
Burns  of  fingers,  332 

of  hand,  332 
Bursa  achillea  anterior,  780 
posterior,  780 
retrocalcanea,  780 
glutei  medii,  519 
minimi,  519 
gluteo-tuberosa,  520 
iliac,  519 

iliaca  posteriori,  520 
popliteal,  hygroma  of,  652 
semimembranosa,  hygroma  of,  652 
serous  inflammation  of,  652 
subcutanea  femoris,  520 
subiliac,  519 

tendinis  obturatoris  interni,  519 
trochanteric,  deep,  519 

superficial,  519 
vaginalis  obturatoris  interni,  519 
Bursa-  of  fingers,  diseases  of,  346 
of  foot,  diseases  of,  780 

treatment  of,  781 
of  hand,  diseases  of,  346 
of  hip,  519 

inflammation  of,  519 


892 


INDEX. 


Bursar  of  knee,  diseases  of,  649 
of  shoulder,  diseases  of,  78 
Bursitis,  acromial,  78 
iniragenualis,  651 
olecranon,  144 
prepatellar,  acute,  650 

treatment  of,  650 
chronic,  650 

symptoms  of,  651 
treatment  of,  651 
tuberculous,  651 
prretibialis,  651 
semimembranosa,  652 
semitendinosa,  652 
subdeltoid,  78 

tuberculous,   79 
subiliac,  521 
trochanteric,  521 
deep,  521 
superficial,  521 
Butterfly  fracture,  139 


CALCANEUM,  dislocation  of,  705 
excision  of,  884 

Ollier's  method,  885 
Rigaud's  method,  884 
fractures  of,  740 
course  of,  749 
diagnosis  of,  7  Is 
treatment  of,  750 
resection  of,  884 

Ollier's  method,  8S5 
Rigaud's  method,  884 
Capitulum  of  humerus,  fracture  of,  188 
diagnosis  of,  189 
symptoms  of,  188 
treatment  of,  189 
Carbolic  gangrene  of  fingers,  341 

of  hand,  341 
Carcinoma  of  femur,  557 
of  foot,  872 
of  hand,  367,  373 
of  humerus,  154 
Carpal  bones,  fracture  of,  300 

treatment  of.  301 
Carpus,  resection  of,  380 
Cavernoma  of  hand.  367 
Cellulitis  of  fingers,  322 
of  foot.  773 
of  hand,  322 
of  leg,  684 
Charcot's  knee-joint.  625 
Chondrofibroma,  cystic,  of  femur.  555 
Chondroma  of  femur,  550 

of  foot,  870 
Chopart's    amputation    at     mediotarsal 
joint,  877 
joint.   / 1  / 

dislocation  in,   765 
Cirsoid  aneurism  of  hand,  368 
treatment  of,  368 
Clavicle,  congenital  defect  of,  17 
diseases  of,  85 
dislocation  of,  34 

acromial  end  of,  35 


Clavicle,  dislocation  of   acromial  end  of, 
downward,   37 

diagnosis  of,  38 
prognosis  of,  38 
symptoms  of,  38 
treatment  of,  38 
upward,  35 

diagnosis  of.  36 
etiology  of.  35 
prognosis  of,  36 
symptoms  of.  35 
treatment  of,  37 
sternal  end  of,  38 

backward,  .40 

diagnosis  of,  41 
etiology  of,  40 
symptoms  of.  40 
treatment  of,  41 
forward,  39 

diagnosis  of,  39 
etiology  of,  39 
prognosis  of,  39 
symptoms  of,  39 
treatment  of,  39 
upward  39 

prognosis  of,  40 
symptoms  of,  40 
treatment  of,  40 
total,  41 

prognosis  of,  41 
symptoms  of.  41 
treatment  of,  41 
excision  of,   110 
fractures  of,  26 

diagnosis  of,  27 
etiology  of.  27 
gunshot,  34 
prognosis  of,  29 
symptoms  of.  ?1 
treatment  of,  30 
neoplasms  of,  85 
resection  of,  110 
syphilis  of,  85 
tuberculosis  of,  85 
tumors  of,  85 
( Ilavus,  774 

subungualis,  776 
Club-foot,  800 

astragalectomy  for,  822 
diagnosis  of,  812 
etiology  of,  800 
pathological  anatomy  of,  807 
svmptoms  of,  812 
treatment  of,  812 
-hand,   congenital,  278 
Colles'  fracture.  286 
Complete  fracture.     See  Fractures. 
Congenital  club-hand,  278 
coxa  vara,  518 
defects  of  clavicle,  17 

of  leg,  669 
dislocation  of  hip,  389 

diagnosis  of,  401 
etiology  of,  389 
pathology  of,  390 
prognosis  of,  401 


INDEX. 


893 


Congenital  dislocation  of  hip,  symptoms 
of,  399 
treatment  of,   102 

of  radius,    I  6  I 
of  shoulder,  18 
elevation  of  scapula,  17 
hypertrophy  of  arm,  117 
malformations  of  foot,  722 
Contracted  foot,  850 
Contractions,  cicatricial,  of  fingers,  :>!!• 

Of  hand,  319 
Contracture  at   elbow,  231 
of  tinners,  356 
of  foot,  795 

paralytic,  795 

treat  incut  of,   797 
of  hand,   356 
of  hip-joint,  502 

diagnosis  of,  504 
paralytic,  510 
symptoms  of,  503 
treatment  of,  505 
of  knee-joint,  626 
prognosis  of,  627 
treatment  of,  627 

by    Braatz'    sector    splint, 

'629 
by  Hessing's  apparatus,029 
by  Schede's  extension,  628 
of  shoulder-joint,  98 
treatment  of,  99 
of  toes,  851 

extension,  856 
flexion,  856 
lateral,  856 
Contusions  of  elbow-joint,  166 
diagnosis  of,  166 
treatment  of,  166 
of  knee,  565 

diagnosis  of,  566 
prognosis  of,  566 
treatment  of,  567 
of  shoulder-joint,  44 
of  wrist,  279 

diagnosis  of,  280 
treatment  of,  280 
Cooper's  method  for  forward  dislocation 

of  shoulder,  68 
Corns,  774 
Coxa  vara,  511 

adolescentium,  513 
diagnosis  of,  516 
pathological    anatomy    of, 

514 
prognosis  of,  517 
treatment  of,  516 
in  arthritis  deformans,  518 
congenital,    518 
Kocher's,  513 
in  osteomalacia,  518 
rhachitic,  518 
traumatic,  519 
Coxitis,  in  acute  osteomyelitis,  458 
course  of,  461 
diagnosis  of,  462 
pathology  of,  458 


Coxitis,  in  acute  osteomyelitis,  prognosis 
of,  462 
symptoms  of,  460 
treatmenl  of,  163 

by  direct  tnfeel  ion,   l"><i 

diagnosis  of,  456 
symptoms  of,    156 
treatmenl  of,  456 

following  infectious  diseases,  453 

gonorrhceal,  454 

in  infancy,  455 

rheumatic,  455 

sypliilit  ic,  455 
traumatic,  453 
tuberculosa,  463 

diagnosis  of,  475 

differential,  479 
pathological  anatomy  of,  463 
prognosis  of,  483 
symptoms  of,  471 
treatment  of,  485 
local,  486 
operative,  493 
typhoid,  455 
Creaking  scapula,  80 
Cubital  adenitis,  143 

artery,  ligation  of,  227 
Cubitus  valgus,  normal,  164 
Curvatures  of  leg,  rhachitic,  706 
treatment  of,  708 
of  thigh,  530 

rhachitic,  530 

treatment  of,  530 
Cysts,  dermoid,  of  thigh,  557 
epithelial,  of  foot,  871 
popliteal,  652 

diagnosis  of,  653 
prognosis  of,  653 
treatment  of,  653 
sebaceous,  of  hand,  369 


DACTYLITIS  syphilitica,  786 
Dactylolysis,  spontaneous,  of  toes, 
774 
Defect,  congenital,  of  clavicle,  17 
of  fibula,  669 
of  foot,  722 
of  forearm,   163 
of  leg,   669 
of  radius,  243 
of  tibia,  669 
of  toes,  669 
of  ulna,  243 
Deformities  of  foot,  795 
paralytic,  795 

treatment  of,  797 
of  hand,  356 
hip,  paralytic,  510 

symptoms  of,  511 
treatment  of,  511 
knee-joint,  paralytic,  633 

static,  634 
of  thigh,  530 

due  to  maldevelopment  of  lower 
epiphysis,  530 


894 


INDEX. 


Deformities  of  thigh,  lower  end  of  femur 
of,  530 
treatment  of,  531- 
phocomelia,  530 

treatment  of,  530 
rhachitic,  530 

treatment  of,  530 
of  toes,  851 
Deltoid  paralysis  following  dislocation  of 
shoulder,  70 
rupture  of,  19 
Dermoid  cysts  of  thigh,  557 
Diabetic  gangrene  of  fingers,  339 
treatment  of,  341 
of  hand,  339 

treatment  of,  341 
Diacondyloid  fracture  of  humerus,  187 
Digits,  supernumerary,  272 
Dislocations  of  astragalus,  total,  762 
diagnosis  of,  763 
treatment  of,  764 
of  biceps  tendon,  19 
of  calcaneum,  765 
in  Chopart's  joint,  765 
of  clavicle,  34 

acromial  end  of,  35 

downward,  37 

diagnosis  of,  38 
prognosis  of,  38 
symptoms  of,  38 
treatment  of,  38 
upward,  35 

diagnosis  of,  36 
etiology  of,  35 
prognosis  of,  36 
symptoms  of,  35 
treatment  of,  37 
sternal  end  of,  38 

backward,  40 

diagnosis  of,  40 
etiology  of,  40 
prognosis  of,  41 
symptoms  of,  40 
treatment  of,  41 
forward,  39 

diagnosis  of,  39 
etiology  of,  39 
prognosis  of,  39 
symptoms  of,  39 
treatment  of,  39 
upward,  39 

diagnosis  of,  40 
symptoms  of,  40 
treatment  of,  40 
total,  41 

prognosis  of,  41 
symptoms  of,  41 
treatment  of,  41 
of  elbow-joint,   198 
backward,  199 

diagnosis  of,  200 
irreducible,  202 
prognosis  of,  201 
treatment  of,  201 
diverging,   206 
forward,  206 


Dislocations  of  elbow-joint,  lateral,  204 
diagnosis  of,  204 
treatment  of,  205 
of  fibula,  681 
of  foot,   751 

lateral,  752 

inward,  754 

symptoms  of,  755 
treatment  of,  755 
outward,   752 

symptoms  of,  752 
treatment  of,  754 
sagittal,  755 

backward,  755 

symptoms  of,  755 
treatment  of,  756 
forward,  756 

diagnosis  of,  757 
symptoms  of,  757 
treatment  of,  757 
upward,  757 

treatment  of,  757 
of  hip,  416 

backward,  417 
bilateral,  432 

prognosis  of,  432 
symptoms  of,  432 
treatment  of,  432 
centrally,  431 

diagnosis  of,  432 
symptoms  of,  432 
treatment  of,  432 
congenital,  389 

diagnosis  of,  401 
etiology  of,  389 
pathology  of,  390 
prognosis  of,  401 
symptoms  of,  399 
treatment  of,  402 
downward,  429 

prognosis  of,  430 
symptoms  of,  430 
treatment  of,  430 
forward,  424 

prognosis  of,  426 
symptoms  of,  425 
treatment  of,  426 
iliac,  417 

diagnosis  of,  421 
prognosis  of,  421 
symptoms  of,  420 
treatment  of    422 
infrapubic,  426 
paralytic,  510 
sciatic,  418 
suprapubic,  424 
upward,  430 

prognosis  of,  431 
symptoms  of.  430 
treatment  of,  431 
voluntary,  432 
of  knee,  583 

backward,  583 

symptoms  of,  584 
treatment  of,  584 
forward,  583 


INDEX. 


895 


!  Hslocationa  of  knee,  forward,  congenital, 
587 
treatment  of,  587 
symptoms  of,  583 

treatment    of,   5N3 

menisci  of,  591 

symptoms  of,  592 
treatment   of,  592 

sideways,  58  I 

complications  of,  585 
diagnosis  of,  585 
symptoms  of,  58  I 
treat  incut    of,  586 
in  mediotarsal  joint,  765 
of  metacarpals,  309 
of  metatarsals,   769 

treatment   of,  770 
of  metatarsus,  total,  769 
diagnosis  of,  770 
prognosis  of,  770 
treatment   of,  770 
of  patella,  588 

congenital,  589 

treatment  of,  590 
downward,   591 
lateral,  588 

prognosis  of,  589 
treatment  of,  589 
vertical,  590 

symptoms  of,  590 

treatment  of,  591 

of  phalanges  of  fingers,  309 

treatment  of,  310 

of  foot,  769 

of  thumb,  311 

mechanism  of,  311 
symptom-  of,  312 
treatment  of,  313 
of  toes,  770 
of  radius,  congenital,  164 
at  elbow,  207 

symptoms  of,  207 
treatment  of,  209 
head  of,  207 
lower  end  of,  303 
of  shoulder,  60 
backward,  71 

infraspinate,  71 

diagnosis  of,  72 
prognosis  of,  72 
symptoms  of,  71 
subacromial,  72 
congenital,  18 

deltoid  paralysis  following,  70 
forward,  61 

axillary,  61 

diagnosis  of,  64 
prognosis  of,  65 
symptoms  of,  64 
treatment  of,  65 
subeoracoid,  61 
habitual,  76 

treatment  of,  77 
old,  73 

anatomy  of,  73 
diagnosis  of,  74 


Dislocations  of 


Bhoulder,  old,  prognos 
of.  7  1 


symptoms  of,  74 
treatment  of,  75 

of  small  tarsals,  7<ili 

subasf  ragaloid,  758 

backward,   760 

forward.  7li() 

inward,  758 

outward,   759 
of  tarsal  bones,  758 
of  tendons  of  loot,  729 

i  reat  ment  of,  730 

of  hand,  280 
of  thumb,  31  1 

mechanism  of,  311 

symptoms  of,  312 

treatment  of,  313 
of  ulna  at  elbow,  207 

lower  end  of,  303 
of  wrist,  301 

single  bones  of,  303 

treatment  of,  302 
Dissector's  tuberculous  axillary  adenitis, 

81 
Dupuytren's  contracture  of  fingers,  362 
splint  for  Pott's  fracture,  739 


ECHINOCOCCl'S  of  femur,  557 
of  humerus,  151 
Eczema  of  axilla,  80 

of  leg,  684 
Enchondroma  of  femur,  555 
of  hand,  370 
of  humerus,  150 
Endothelioma  of  foot,  871 
Elbow,  contracture  at,  231,  241 
infusion  at,  235 
-joint,  amputations  at,  226 
anatomy  of,   161 
arteries  at,  ligation  of,  227 
arthritis  deformans  of,  212 
contusions  of,  166 
diagnosis  of,  166 
treatment  of,  166 
diseases  of,  210 
dislocations  of,  198 
backward,  199 

diagnosis  of,  200 
prognosis  of,  201 
treatment  of,  201 
diverging,   206 
forward,  206 
lateral,  204 

diagnosis  of,  204 
treatment  of,  205 
of  radius  at,  207 

symptoms  of,  207 
treatment  of,  209 
of  ulna  at,  207 
fractures  of,  167 

complicated,  196 
gunshot,  196 
free  bodies  in,  213 

symptoms  of,  213 


896 


IXLEX. 


Elbow-joint,  gout  of,  212 

inflammation    of,  acute    serous, 
210 

treatment  of,  210 
ehronic,  212 
injuries  of,  1  66 
ligation  of  arteries  at.  227 
location  of  nerves  at,  227 
loose.   225 

malformations  of,  163 
mechanism  of,  161 
operations  on.  222 
resection  of.  222 
sprains  of,  166 

diagnosis  of,  167 
prognosis  of,  167 
treatment  of,  167 
suppuration  of,  211 
syphilis  of.  211 
tuberculosis  of,  215 
prognosis  of,  216 
symptoms  of,  215 
treatment  of,  217 
wounds  of,  gunshot,  197 
median  nerve,  injuries  of,  237 
nerves  at,  diseases  of,  236 

injuries  of,  236 
operation  on,  259 
radial  nerve  at.  injuries  of,  236 
skin  of,  contraction  of,  231 
diseases  of,  229 
injuries  of,  229 
soft  parts  of,  injuries  of,  229 
synovial  sacs  at,  diseases  of,  233 

injuries  of,  233 
tendons  of,  diseases  of,  233 

injuries  of,  233 
ulnar  nerve  at,  injuries  of,  238 
vessels  of,  diseases  of,  234 

injuries  of,  234 
wing-skin  at.  229 
Elephantiasis  of  leg,  695 
prognosis  of,  696 
treatment  of,  696 
nervorum  (v.  Brims)  of  thigh,  558 
En  chondroma  of  femur.  555 
Endothelioma  of  foot.  871 
Epiphysis  of  humerus,  lower,  separation 

of,  187 
Epithelial  cysts  in  foot.  871 
Erysipelas  of  arm.  143 
of  fingers.  330 
of  hand,  330 
of  leg,  684 
Evulsion  of  upper  arm.  141 
Exarticulation  of  hand.  377 

at  knee,  713 
Excision  of  astragalus,  885 
of  calcaneum,  884 

Ollier's  method,  885 
Rigaud's  method,  884 
of  clavicle,  110 
Exercise-bone,  84 
Exostosis  in  foot,  s7o 
of  humerus.  150 

prognosis  of,   151 


Exostosis  of  humerus,  treatment  oi",  lo'l 
Extension  treatment   of    supracondyloid 
fractures,  176 


FALSE  joint.    See  also  Pseudarthrosis. 
Felon.  322 
Femoral  artery,  aneurism  of,  549 
injuries  of,  532 
ligation  of,  559 
vein,  injuries  of.  532 
Femur,  carcinoma  of,  557 
chondro fibroma  of,  555 
chondroma  of.  556 
diseases  of,  551 
echinococcus  of,  557 
enchondroma  of,  555 
fibroma  of,  556 
fracture  of.  condyles  of,  571 
prognosis  of,  572 
treatment  of,  572 
epiphyseal  lines  of,  449 

diagnosis  of,  449 
prognosis  of,  449 
symptoms  of.  449 
treatment  of,  449 
great  trochanter  of,  448 

symptoms  of,  448 
treatment  of,  449 
gunshot,  5  16 
head  of,  434 
neck  of,  435 

diagnosis  of,  442 
pathology  of,  436 
prognosis  of,  443 
symptoms  of,  439 
treatment  of,  445 
shaft  of.  535 

complete,  536 
multiple.  537 
oblique,  536 
prognosis  of,  539 
spiral,  537 
splinter,  537 
symptoms  of,  538 
torsion  in,  535 
treatment  of,  539 
v.  Bruns',  540 
Buck'.-  extension,  545 
extension,  540 
Helferich's    extension, 

541 
Hessing's,  542 
Hodgen's     suspension, 

545 
Schede's      suspension, 

541 
v.  Yolkmann's,  540 
upper  end  of,  433 
lipoma  of,  556 
myxoma  of,  556 
osteomyelitis  of,  acute,  551 
symptoms  of,  552 
treatment  of.  554 
sarcoma  of,  556 

treatment  of.  557 


INDEX. 


897 


Femur,  shaft  of,  gunshot  wounds  of,  540 
infraction  of,  530 
tumors  of,  555 
osteoid,  556 
Fenestrated  splint  for  leg,  679 
Fibroma  of  femur,  556 
of  hand,  369 

diagnosis  of,  369 
treatment  of,  369 
Fibula,  dislocation  of,  681 
fractures  of,  680 
tuberculosis  of,  703 
treatment  of,  705 
Fingers,  acute  inflammatory  processes  of , 
321 
amputation  of,  378 
bones  of.  diseases  of,  346 
burns  of,  332 
bursae  of,  diseases  of,  342 
cellulitis  of,  322 
cicatricial  contractions  of,  319 
contractures  of,  356 
erysipelas  of,  330 
frostbites  of,  332 

prognosis  of,  332 
treatment  of,  332 
furuncle  of,  329 

treatment  of,  329 
gangrene  of.  carbolic,  341 
diabetic,  339 

treatment  of,  341 
presenile,  33S 
senile,  338 
glossy,  317 

joints  of,  diseases  of,  346 
leprosy  in,  local  effect-  of,  337 
lymphangitis  of,  331 
operations  on,  374 
panaritium  of,  articular,  324 
course  of,  325 
treatment  of,  326 
cutaneous.  322 
osseous,  324 
parungual.  •'•52:! 
subungual,  323 
phalanges  of,  dislocations  of,  309 
treatment  of,  310 
fractures  of,  308 

diagnosis  of,  308 
treatment  of,  308 
resection  of,  384 
phlebitis  of,  331 
post-traumatic  neuritis  of,  318 

periostitis  of,  320 

pseudoerysipelas  of,  330 

prognosis  of.  331 

symptoms  of,  330 

skin  of,  tuberculosis  of,  333 

snapping.  363 

soft  parts  of,  infection  of.  acute.  329 
subacute,  329 
inflammation    of,    chronic, 
333 
spina  ventosa  of,  353 
syphilis  of,  primary  effects  of,  329 
syphilitic  affections  of,  336 
Vol.  III.— 57 


Fingers,  syringomyelia  in,  local  effects  of, 
337 
tendon  Bheaths  of,  diseases  of,  342 
panaritium  of.  323 

suppuration  of,  323 
tenosynovitis  of.  343 

gonorrhoea^  343.  345 
bj  philitic,  315 
tuberculous,  343 
traumatic  changes  in  joints  of,  319 
trigger,  363 

trophic  disturbances  of,  337 
tuberculosis  of.  35  I 
symptoms  of,  355 
treatment  of,  355 
wounds  of,  31 I 

serious  results  of.  317 
Fink  and  Heusner's  adhesive  mixture,  817 
Flat-foot,  829 

diagnosis  of,  837 
etiology  of,  829 
mechanism  of  origin  of,  831 
pathological  anatomy  of.  835 
shoe  for,  842 
static,  S30 
symptoms  of,  837 
treatment  of,  842 
Foot,  ainhum  of,  774 
anatomy  of,  717 
aneurism  of.  862 

diagnosis  of.  862 
treatment  of,  862 
angioma  of,  870 
arthritis  deformans  of,  785 
treatment  of,  785 
bones  of.   inflammations  of,   acute, 
781 
chronic,   7s*  i 
tuberculosis  of,  785 
diagnosis  of,  788 
frequency  of,  786 
symptoms  of,  787 
treatment  of,  790 
bursae  of,  diseases  of,  780 

tn-atment  of,  781 
carcinoma  of.  872 
cellulitis  of,  773 
chondroma  of.  870 
chronic  rheumatism  of,  784 
clavus  of.  774 
club-,  800 

diagnosis  of.  812 
etiologv  of.  800 
pathological  anatomy  of,  807 
symptoms  of.  812 
treatment  of,  812 
contracted,  850 
contractures  of,  795 
paralytic.  795 
treatment  of,  797 
dactylolysis  of,  774 
defects  of,  722 
deformities  of,  795 
paralytic,  795 

treatment  of,  797 
diseases  of,  773 


898 


INDEX. 


Foot,  dislocations  of,  751 
lateral,  752 

inward,  754 

symptoms  o.,  755 
treatment  of,  755 
outward,  752 

symptoms  of,  752 
treatment  of,  754 
sagittal,  755 

backward,  755 

symptoms  of,  755 
treatment  of,  756 
forward,  756 

diagnosis  of.  757 
symptoms  of,  757 
treatment  of,  757 
upward,  757 

treatment  of,  757 
endothelioma  of,  871 
epithelial  cysts  in,  871 
exostosis  in,  870 
flat-,  829 

diagnosis  of,  837 
etiology  of,  S29 
mechanism  of,  origin  of,  831 
pathological  anatomv  of,  835 
shoe  for,  842 

of  Beely,  843 
of  Miller  and  Thomas,  843 
static,  830 
symptoms  of,  837 
treatment  of,  842 
gangrene  of,  862 
diabetic,  864 
embolic,  865 
frostbite,  865 
presenile,  863 
Ravnaud's,  865 
senile,  862 
treatment  of,  866 
gout  of,  785 

treatment  of,  785 
hollow,  850 
hypertrophy  of,  722 
inflammations  of,  acute,  773 
treatment  of,  773 
chronic,  773 
injuries  of,  728 

joints  of,    inflammations  of,   acute, 
781 
chronic,  784 
tuberculosis  of,  785 
diagnosis  of,  788 
frequency  of,  786 
-ymptoms  of,  787 
treatment  of,  790 
leprosy  of,  774 
lipoma  of,  870 
lupus  of,  774 
Madura,  774 
malformations  of,  722 
metatarsals  of.  dislocations  of,  769 
fractures  of,  768 

prognosis  of,  769 
treatment  of,  769 
injuries  of,  768 


Foot,  nails  of,  diseases  of,  775 
neoplasms  of,  870 
benign,  870 
malignant,  871 
nerves  of,  diseases  of,  862 
neuropathic  affections  of,  867 
operations  on,  873 
osteoma  of,  870 
osteosarcoma,  871 
papilloma  in,  871 
phalanges  of,  dislocations  of,  769 
fractures  of,  768 

prognosis  of,  769 
treatment  of,  769 
injuries  of,   768 
phlegmon  of,   773 
physiology  of,  717 
sarcoma  of,  871 

subungual,  871 
sensory  disturbances  of.  869 

treatment  of.  870 
skin  of,  leprosy  of,  774 
lupus  of,  774 
syphilis  of.   774 
tuberculosis  of,  774 
subungual  growths  in.  870 
as  a  supporting  arch,  831 
syphilis  of,  774 

syphilitic  affections  of  skeletal,  785 
telangiectasis  of,  870 
tendon  sheaths  of,  anatomy  of,  778 
diseases  of,  778 

treatment  of,  780 
dislocations  of,  729 

treatment  of,  730 
injuries  of,   729 
lacerations  of,  730 

treatment  of,  730 
transplantation  in,   798 
trophic  disturbances  of,  869 

treatment  of,  870 
tumors  of,  768,  870 
ulcers  of,  perforating,  867 
treatment  of,  868 
vessels  of,  diseases  of,  862 
warts  in.  871 
Forearm,  amputation  of,  259 
bones  of,  fractures  of.  246 
upper  end  of,  189 
injuries  of.  247 
malformations  of,  243 
osteomyelitis  of,   255 
tumors  of,  257 
defects  of,  163 
malformations  of,  163 
nerves  of.  operations  on,  261 
operations  on,   259 
paralvsis  of,  tendon  transplantation 

tor.  240 
tendons  of,  diseases  of,  233 

injuries  of,  233 
vessels  of,  diseases  of.  234 
injuries  of,  234 
Foreign  bodies  in  hand,  316 
Fractures  about  the  malleoli,  731 
of  astragalus,  744 


INDEX. 


809 


Fractures  of  astragalus,  diagnosis  of ,  <  15 
treatment  of,  746 
of  bones  of  forearm,  2 16 

upper  ends  of,  189 
of  shall  of  leg,  ti7l 
butterfly,  L39 
of  calcaneum,  7  Mi 
eourse  of,  7  19 
diagnosis  of,  748 
treatment  of,  750 
of  carpal  bones,  300 

treatment  of,  301 
of  clavicle,  26 

diagnosis  of,  27 
etiology  of,  27 
gunshot,  34 
prognosis  of,  29 
symptoms  of,  27 
treatment  of,  30 
Colles',  286 
of  elbow-joint,  167 
complicated,  196 
gunshot,  196 
of  lemur,  condyles  of,  571 
prognosis  of,  572 
treatment  of,  572 
epiphyseal  lines  of,  449 

diagnosis  of,  449 
prognosis  of,  449 
symptoms  of,  449 
treatment  of,  449 
great  trochanter  of,  448 

symptoms  of,  448 
treatment  of,  449 
gunshot,  546 
head  of,  434 
neck  of,  435 

diagnosis  of,  442 
pathology  of,  436 
prognosis  of,  443 
symptoms  of,  439 
treatment  of,  445 
shaft  of,  535 

complete,  536 
multiple,  537 
oblique,  536 
prognosis  of,  539 
spiral,  537 
splinter,  537 
symptoms  of,  538 
torsion,  535 

treatment  of,  539.     See  also 
Splints, 
of  fibula,  680 
of  humerus,  49 

anatomical  neck  of,  50 
prognosis  of,  51 
symptoms  of,  50 
treatment  of,  51 
capitulum  of,  188 
diagnosis  of,  189 
symptoms  of,  188 
treatment  of,  189 
complicated,  132 
condyles  of,   177 
external,  181 


Fractures  of  humerus,  condyles  of,  ex- 
terna], cause  of,  181 
diagnosis  of,  182 
mechanism  of,  181 
prognosis  of,  182 
symptoms  of,  181 
treatment  of,  182 
diacondyloid,  L87 
epicondyles  of,  external,   183 
treat  nient  of,   184 
internal,   184 
in  epiphysis,  52 

diagnosis  of,  53 
prognosis  of,  53 
symptoms  of,  53 
treatment  of,  54 
infratubercular,   52 
lower  end  of,  167 
shaft  of,  128 

etiology  of,  128 
prognosis  of,  129 
symptoms  of,  129 
treatment  of,   129 
supraeondyloid,   169 
diagnosis  of,  172 
etiology  of,  169 
mechanism  of,  169 
prognosis  of,  176 
symptoms  of,  171 
treatment  of,  172 
surgical  neck  of,  54 
prognosis  of,  55 
symptoms  of,  55 
treatment  of,  56 
T-  and  Y-fractures,  177 
diagnosis  of,  178 
etiology  of,  177 
mechanism  of,  177 
symptoms  of,  178 
treatment  of,  178 
through  the  tuberosity,  52 
tuberosities  of,  59 
uniting  with  deformity,  138 
upper  end  of,  49 

intracapsular,  50 
supratubercular,   50 
of  leg,  671 

intrauterine,  669,  670 
of  malleoli,  733 

diagnosis  of,  738 
mechanism  of    733 
symptoms  of,  737 
treatment  of,  738 
of  metacarpals,  306 

treatment  of,  307 
of  metatarsals,  768 
prognosis  of,  769 
treatment  of,  769 
of  patella,  573 
cause  of,  575 
compound,  579 

treatment  of,  579 
prognosis  of,  575 
symptoms  of,  575 
treatment  of,  576 
ambulant,  576 


900 


INDEX. 


Fractures  of  patella,  treatment   of.  am- 
l.ulant.    of    Kraske. 
57  s 
of  zum  Bu.-ch.  •"',  v 
by  bandaging.  57b' 
Bardenheuer's    extension, 

576 
Malgaigne's  clamps,  576 
by  massage.  576 
open  suture,  578 

of   Dieffenbaeh, 

578 
of  Lister.  "7v 
of    Rhea    Barton, 

578 
of  Severino,  5 .  s 
osteoplastic,  580 
Helferich's,  580 
Rosenberger's,  580 
Tenderich's,  580 
Wolff's.  580 
by  resection,  580 
subcutaneous  suture,  577 
of  Barker's,   577 
of  Butcher,  577 
of  Ceci.  577 
of  Heuner.   577 
of  Kocher.   577 
of    v.    Yolkmann, 
577 
Trelat's  method,  576 
of  phalanges  of  finger,  308 
diagnosis  of,  308 
treatment  of.  308 
of  foot,  768 

prognosis  of,  769 
treatment  of.  769 
Pott's,  733 

of  radius,  head  of.  194 
etiology  of.  194 
symptoms  of,  194 
treatment  of.  194 
lower  end  of.  286 

after-treatment  of.  299 
anatomical  finding-  of. 

289 
diagnosis  of.  293 
mechanism  of,  287 
prognosis  of.  299 
symptoms  of.  292 
treatment  of,  295 
neck  of,  195 

diagnosis  of.  195 
symptoms  of.  195 
treatment  of,  195 
shaft  of,  253 

diagnosis  of.  254 
etiology  of.  254 
treatment  of.  254 
and  ulna,  shaft  of.  247 

prognosis  of.  248 
symptoms  of,  247 
treatment  of.  249 
of  scapula,  41 

acromion  and  spine.  44 
prognosis  of.  45 


Fractures  of  scapula,  acromion  and  spine, 
symptoms  of.  44 
treatment  of,  45 
anales  of.  42 
body  of,  42 

prognosis  of.  42 
symptoms  of.  42 
treatment  of,  42 
coracoid  process  of.  45 
etiology  of,  45 
symptoms  of.  45 
treatment  of.  45 
glenoid  portion  of,  43 
gunshot,  45 
surgical  neck  of.  43 
prognosis  of.  44 
symptoms  of,  44 
treatment  of,  44 
of  small  tarsal  bones.  750 

treatment  of,  751 
supramalleolar,  731 
diagnosis  of,  732 
prognosis  of,  733 
treatment  of,  733 
of  tarsus,  744 
of  tibia  and  fibula,  671 
shaft  of,  671 

diagnosis  of,  674 
prognosis  of,  675 
treatment  of,  676 
tuberosities  of,  572 
treatment  of,  573 
of  ulna,  coronoid  process  of,  189 
prognosis  of,  190 
symptoms  of,  190 
treatment  of.  190 
olecranon  process  of,   190 
prognosis  of,  192 
svmptoms  of.  190 
treatment  of,  192 
shaft  of.  251 

etiology  of,  251 
symptoms  of,  252 
treatment  of.  253 
Free  bodies  in  elbow-joint.  213 
in  knee-joint.  621 

diagnosis  of,  623 
symptoms  of.  623 
treatment  of.  623 
Frostbites  of  fingers.  332 
prognosis  of.  332 
treatment  of.  332 
of  hand.  332 

prognosis,  of.  332 
treatment  of.  332 
Furuncle  of  axillarv,  80 
of  finger>.  329 

treatment  of.  329 
of  hand.   329 

treatment  of.  329 
of  leg.  684 


G 


ANGLION  of  knee.  653 
of  wrist.  365 

treatment  of,  366 


INDEX. 


901 


Gangrene  of  fingers,  carbolic,  341 
diabetic,  339 

treatment  of,  341 

presenile,  338 
senile,  338 
of  foot,  S62 

earbolic,  865 
diabetic,  864 
frostbite,  865 
presenile,  863 
Raynaud's,  865 
senile,  862 
treatment  of,  866 
of  hand,  338 

carbolic,  341 
diabetic,  339 

treatment  of,  341 
presenile,  338 
senile,  338 
Genu  valgum,  634 

adolescent ium,  634 
rhachitic,  634 
treatment  of,  640 
varum,  645 

treatment  of,  646 
Gibney's  dressing  for  sprained  ankle,  729 
Glands,  inguinal,  inflammation  of,  522 
suppurative,  522 
syphilitic,   522 
Glossy  finger,  317 
Goldschmidt's     apparatus     for     talipes 

equinus,  828 
Gonorrhoea  of  hand,  346 
Gonorrheal  coxitis,  454 

tenosynovitis  of  fingers,  343,  345 
of  hand, 343, 345 
Gout  of  elbow-joint,  212 
of  foot,   785 

treatment  of,  785 
of  hand,  348 
Groin,  tumors  of,  557 
Guerin's  method  for  ulcers  of  leg,  687 
Gumma  of  muscles  of  upper  arm,  144 
Gunshot  fracture.     See  Fractures, 
of  clavicle,  34 
injuries  of  upper  arm,  139 

diagnosis  of,  140 
treatment  of,  140 
wounds  of  elbow-joint,  197 
of  hip-joint,  450 

diagnosis  of,  451 
prognosis  of,  451 
treatment  of,  451 
of  knee-joint,  569 
of  thigh,  546 
Giinther's  incision,  877 
Gussenbauer's  staple,  137 


HABITUAL  dislocations  of  shoulder, 
76 
treatment  of,  77 
subluxation  of  knee,  587 
Hemangioma  of  hand,  367 

of  thigh,  557 
Hemarthrosis  of  knee,  566 


Haematoma  of  axilla,  22 
Haemophilia,  knee-joint  in,  615 
prognosis  of,  616 
treatment  of,  616 
Hallux  valgus,  851 

treatment  of,  854 
varus,  855 
Hamilton's  extension  splint,   131 
Hammer-toe,  856 

treatment  of,  857 
Hand,  acute  inflammatory  processes  of, 
321 
amputation  of,  377 
anatomy  of,  265 
ankylosis  of,  356 
bones  of,  acromegaly  of,  351 
diseases  of,  346 
inflammation  of,  acute,  346 

chronic,  348 
tuberculosis  of,  351 
burns  of,  332 
bursa3  of,  diseases  of,  342 
carcinoma  of,  367,  373 
cavernoma  of,  367 
cellulitis  of,  322 
cicatricial  contraction  of,  319 
cirsoid  aneurism  of,  368 

treatment  of,  368 
congenital  hypertrophy  of,  270 
contractures  of,  356 
deformities  of,  356 
development  of,  270 
enchondroma  of,  370 
erysipelas  of,  330 

treatment  of,  330 
exarticulation  of,  377 
fibroma  of,  369 

diagnosis  of,  369 
treatment  of,  369 
foreign  bodies  in,  316 
frostbites  of,  332 

prognosis  of,  332 
treatment  of,  332 
furuncle  of,  329 

treatment  of,  329 
gangrene  in,  carbolic,  341 
diabetic,  339 

treatment  of,  341 
presenile,  338 
senile,  338 
gout  of,  348 
hemangioma  of,  367 
joints  of,  arthritis  deformans  of,  348 
diseases  of,  346 
gonorrhoea  of,  346 
gout  of,  348 
inflammation  of,  acute,  346 

chronic,  348 
neuropathic  arthritis  of,  350 
rheumatism  of,  346 
suppuration  of,  347 
syphilis  of,  hereditary,  349 
treatment  of,  350 
traumatic  effusion  of,  347 
leprosy  in,  local  effects  of,  337 
lipoma  of,  368 


902 


ISDEX. 


Hand,  lipoma  of,  diagnosis  of,  3G8 
treatment  of,  369 
lymphangitis  of,  331 
malformations  of,  270 
moles  of,  367 

nsevus  pigmentosus  of,  367 
neoplasms  of,  365 
neuroma  of,  370 
neuropathic  arthritis  of,  350 
operations  on,  374 
osteoma  of,  372 
phlebitis  of,  331 
phlegmonous  processes  of,  321 
post-traumatic  neuritis  of,  318 

periostitis  of,  320 
pseudoerysipelas  of,  330 
prognosis  of,  331 
symptoms  of,  331 
sarcoma  of,  372 
sebaceous  cysts  of,  369 
skin  of,  tuberculosis  of,  333 

treatment  of,  336 
soft  parts  of,  infections  of,  acute,  329 
chronic,  333 
subacute,  329 
syphilis  of,  331 

hereditary,  349 
primary  effects  of.  329 

treatment  of,  330 
syphilitic  affections  of,  336 
syringomyelia  in,  local  effects  of,  337 
telangiectasis  of,  367 
tendons  of,  dislocation  of,  280 
open  division  of,  282 
operations  on,  283 

plastic,  375 
sheaths  of,  265 

diseases  of,  342 
subcutaneous  laceration  of,  281 
suture  of,  283 
tenosynovitis  of,  343 

gonorrhoeal,  343,  345 
syphilitic,  345 
tuberculous,  343 
traumatic  changes  in  .pints  of,  319 
trophic  disturbances  of,  337 
tumors  of,  365 
warts  of,  367 

treatment  of,  367 
wounds  of,  314 
Heidenhain's    traction    loop    for    talipes 

equinus,  828 
Hemimelia,  117 
Hennequin's  bone-suture,  136 
Hernia  of  muscles  of  arm,  119 
of  thigh,  534 

treatment  of.  535 
Heusner's      apparatus      for      fractured 

clavicle,  31 
High  shoulder,  17 
Hip,  anatomy  of,  385 
bursse  of,  519 

inflammation  of,  519 
diseases  of,  452 
dislocation  of,  41  (i 
backward,  417 


Hip,  dislocation  of,  bilateral,  432 
prognosis  of,  432 
symptoms  of,  432 
treatment  of,  432 
centrally,  431 

diagnosis  of,  432 
symptoms  <>\.  432 
treatment  of,  432 
congenital,  389 

diagnosis  of,  401 
etiologv  of,  389 
pathology  of,  390 
prognosis  of,  401 
symptoms  of,  399 
treatment  of,  402 
downward,  429 

prognosis  of,  430 
symptoms  of,  430 
treatment  of,  430 
forward,  424 

prognosis  of,  426 
symptoms  of,  425 
treatment  of,  426 
iliac,  417 

diagnosis  of,  421 
prognosis  of,  421 
symptoms  of.  420 
treatment  of,  422 
infrapubic,  424 
sciatic,  418 
suprapubic,  424 
upward,  430 

prognosis  of,  431 
symptoms  of,  430 
treatment  of,  431 
voluntary,  432 
injuries  of,  416 
-joint,  amputation  of,  527 
Franke's,  528 
hsemostasis  in,  527 

Braun's  method  of,  527 
Bunger's    method    of, 

527 
Davy's  method  of,  527 
v.  Esmarch's    method 

of,  527 
Larrey's  method  of  ,527 
Riedel's  method  of  .527 
Rose's  method  of,  527 
McBurnev's  method  of, 

527 
Schonborn's  method  of, 

527 
Trendelenburg's  meth- 
od of ,  527 
Kocher's  resection,  599 
mortality  of,  529 
Quenu's,  528 
Rose's,  527 
subperiosteal,  528 

of  Vetch  and  Ravaton, 

528 
of  v.  Yolkmann,  528 
transfixion  method,  527 
Verneuil's,  527 
ankvlosis  of,  502 


INDEX. 


903 


Hip-joint,  ankylosis  of,  diagnosis  of,  504 
symptoms  of,  503 
treatment  of,  505 
ambulant,  505 
forcible  reduction,  505 

Hoffa's  apparatus,  f>07 

Lorenz'  apparatus,  506 
operative,  508 

arthritis  deformans  of,  494 
diagnosis  of,  497 
etiology  of,   197 
pathology  of,    195 
prognosis  of,  499 
symptoms  of,  497 
treatment  of,  499 
contracture  of,  502 
diagnosis  of,  504 
paralytic,  510 
symptoms  of,  504 
treatment   of,  505 
coxitis  from  acute  osteomyelitis, 
458 
course  of,  461 
diagnosis  of,  462 
pathology  of,  458 
prognosis  of,  462 
symptoms  of,  460 
treatment  of,  463 
by  direct  infection,  456 

diagnosis  of,  456 
symptoms  of,  456 
treatment  of,  456 
following     infectious      dis- 
eases, 453 
gonorrhceal,  454 
in  infancy,  455 
rheumatism  of,  acute  artic- 
ular, 455 
syphilitic,  455 
traumatic,  453 
typhoid,  455 
deformities  of,  paralytic,  510 
symptoms  of,  511 
treatment  of,  511 
dislocation  of,  paralytic,  510 
hysterical,  501 
inflammation  at,  452 

pathological    anatomy    of, 
425 
loose,  510 
neuralgia  of,  501 
neuropathic  affections  of,  501 
resection  of,  524 

Bardenheuer  and  Schmidt 's, 

526 
Huter's,  525 
Kocher's,  524 
Konig's,  524 
Langenbeck's,  524 
Liicke's,  525 
Roser's,  525 
Schede's,  525 
Sprengel's,  525 
Tiling's,  524 
of  syringomyelia,  501 
of  tabes,  501 


Hip-joint,  tuberculosis  of,  in:; 
diagnosis  of,   17.", 

differential,   »7'.» 
pathological    anatomy    of, 

463 
prognosis  of.   is:; 
symptoms  of,  471 
treatment   of,    IS.", 
local,  486 
wounds  of,  gunshot ,    150 
diagnosis  of,  451 
prognosis  of,  451 
treatment  of,  451 
malformations  of,  389 
operation   at,   524 
physiology  of,  385 
Hoffa's  apparatus  for  talipes  calcaneus, 

849 
Hofmeister's  method  for  forward  disloca- 
tion of  shoulder,  69 
dressing  for  dislocation  of  clavicle,  37 
Hoftmann's  prothesis  for  thigh,  564 
Holden's  toepost,  854 
Hollow  foot,  850 
Housemaid's  knee,  650 
Hudson's  apparatus  for  talipes  equinus, 

828 
Humerus,  aneurism  of,  151 
carcinoma  of,  154 
echinococcus  of,  151 
enchondroma  of,  150 
exostosis  of,  150 

prognosis  of,  151 
treatment  of,  151 
fractures  of,  49 

anatomical  neck  of,  49 

intrascapular,  50 
supratubercular,  50 
capitulum  of,  188 
diagnosis  of,  189 
symptoms  of,  188 
treatment  of,  189 
complicated,   132 
condyles  of,  177 
external,   181 

cause  of,  181 
diagnosis  of,  182 
mechanism  of,  181 
prognosis  of,  182 
symptoms  of,  181 
treatment  of,  183 
internal,  186 

prognosis  of,  187 
treatment  of,  187 
diacondyloid,   187 
epicondyles  of,  183 
external,  183 

treatment  of,  184 
internal,  184 
in  epiphysis,  52 

diagnosis  of,  53 
prognosis  of,  53 
symptoms  of,  53 
treatment  of,  54 
infratubercular,  52 
lower  end  of,  167 


904 


INDEX. 


Humerus,  fractures  of,  shaft  of,  128 
etiology  of,   128 
prognosis  of,  129 
symptoms  of,  129 
treatment  of,  129 
supracondyloid,  169 
diagnosis  of,   172 
etiology  of,  169 
mechanism  of,  169 
prognosis  of,  176 
symptoms  of,  171 
treatment  of,  172 
surgical  neck  of,  54 

prognosis  of,  55 
symptoms  of,  55 
treatment  of,  56 
T-  and  Y-fractures,  177 

diagnosis  of,  178 
etiology  of,  177 
mechanism  of,  177 
symptoms  of,  178 
treatment  of,  178 
through  the  tuberosity,  52 
tuberosities  of,  59 
uniting  with  deformity,  138 
upper  end  of,  49 

intracapsular,  50 
supratubercular,  50 
osteomyelitis  of,  147 
pseudarthrosis  of,  134 

anatomical  findings  of,  135 
diagnosis  of,  135 
etiology  of,  134 
prognosis  of,  135 
treatment  of,  135 
resection  of,  157 
sarcoma  of,  151 

diagnosis  of,  153 
prognosis  of,  153 
syphilis  of,  149 
tuberculosis  of,  149 
tumors  of,  149 
Hydroadenitis  axillaris,  80 
Hydrops,  intermittent,  of  knee-joint,  599 
Hygroma  of  thigh,  557 
Hypertrophy,  congenital,  of  foot,  722 

of  hand,  270 
Hysterical  hip-joint,  501 
shoulder-joint,  102 


"NFLAMMATIONS  of  ankle,  acute,  773 
treatment  of,  773 
chronic,  773 
joint,  781 

treatment  of,  782 
of  bones  of  foot,  acute,  781 
chronic,  784 
of  hand,  acute,  346 
chronic,  348 
of  bursse  of  hip,  519 
of  elbow-joint,  acute  serous,  210 
treatment  of,  210 
chronic,  212 
of  foot,  acute,  773 

treatment  of,  773 


Inflammations  of  foot,  chrome,  773 
of  hip-joint,  452 
of  inguinal  glands,  522 

suppurative,  523 
syphilitic,  522 
of  joints  of  foot,  acute,  781 
chronic,  784 
of  hand,  acute,  346 
chronic,  348 
of  knee-joint,  acute  exudative,  594 
chronic  deforming,  619 

symptoms  of,  620 
treatment  of,  620 
of  metatarsal  bones,  783 

treatment  of,  784 
of  metatarsals  in  infectious  diseases, 

784 
of  tibiotarsal  joint,  781 

treatment  of,  782 
Inflammatory  diseases  of  shoulder-joint, 
89.     See  Omarthritis, 
processes  of  axilla,  80 

treatment  of,  81 
of  fingers,  acute,  321 
of  hand,  acute,  321 
of  thigh,  551 

and  ulcers  of  soft  parts  of  leg, 
684 
Infraction.     See  Fractures. 
Infragenual  bursitis,  651 
Infusion  at  elbow,  235 
Ingrowing  toe-nail,  776 

treatment  of,  777 
Inguinal  adenitis,  522 

suppurative,  522 
syphilitic,  522 
glands,  inflammation  of,  522 
suppurative,  522 
syphilitic,  522 
Lennander's  operation  for,  560 
tumors  of,  557 
region,  tumors  of,  557 
Intermittent  hydrops  of  knee-joint,  599 
Interscapulothoracic       amputation       of 

shoulder,  112 
Intrauterine  fracture  of  leg,  670 


JOINTS,  ankle,  amputation  of,  873 
anatomy  of,  717 
inflammation  of,  acute,  781 
treatment  of,  782 
injuries  of,  728 

complicated,  766 

treatment  of,  767 
compound,   766 

treatment  of,  767 
physiology  of,  717 
resection  of,  880 

by  anterior  transverse  in- 
cision, 884 
sprains  of,  728 

treatment  of,  728 
synovitis  of,  acute,  781 

gonorrhoea!,  782 
hemorrhagic,  782 


INDEX. 


905 


Joints,  ankle,  synovitis  of,  acute,  in    in- 
fectious  diseases,  782 

serous,   7S1 
suppurative,   782 
treatment   of,  782 
Chopart's,  717 
elbow-,  amputations  at,  226 
anatomy  of,  161 
arteries  at,  ligation  of,  227 
arthritis  deformans  of,  212 
contusions  of,  166 
diagnosis  of,  166 
treatment  of,   166 
diseases  of,  210 
dislocations  of,  198 
backward,   199 

diagnosis  of,  200 
irreducible,  202 
prognosis  of,  201 
treatment  of,  201 
diverging,  206 
forward,  206 
lateral,  204 

diagnosis  of,  204 
treatment  of,  205 
of  radius  at,  207 

symptoms  of,  207 
treatment  of,  209 
of  ulna  at,  207 
fractures  of,  167 

complicated,   196 
gunshot,  196 
free  bodies  in,  213 

symptoms  of,  213 
gout  of,  212 
inflammations  of,  210 
injuries  of,  166 
ligation  of  arteries  at,  227 
locations  of  nerves  at,  227 
loose,  225 
mechanism  of,  161 
operations  on,  222 
resection  of,  222 
sprains  of,  166 

diagnosis  of,  167 
prognosis  of,  167 
treatment  of,   167 
suppuration  of,  211 
syphilis  of,  211 
tuberculosis  of,  215 
prognosis  of,  216 
symptoms  of,  215 
treatment  of,  217 
wounds  of,  gunshot,   197 
of  finger,  diseases  of,  346 

traumatic  changes  in,  319 
of  foot,  inflammations  of,  acute,  781 
chronic,   784 
tuberculosis  of,  785 
diagnosis  of,  788 
frequency  of,  786 
symptoms  of,  787 
treatment  of,  790 
of  hand,  arthritis  deformans  of,  348 
diseases  of,  346 
gonorrhoea  of,  346 


Joints  of   hand,  gout  of,  348 

inflammations  of,  346,  348 
neuropathic  arthritis  of,  350 
rheumat  ism  of,  15 16 
suppuration  of,  347 
syphilis  of,  hereditary,  349 
traumatic  effusion  in,  347 
hip-,  amputation  of,  527 
Franke's,  528 
haemostasia  in,  527 
Kocher's  resection  of,  599 
mortality  of,  529 
Quenu's,  528 
Rose's,  527 
subperiosteal,  528 
transfixion  method,  527 
Verneuil's,  527 
ankylosis  of,  502 

diagnosis  of,  504 
symptoms  of,  503 
treatment  of,  505 
arthritis  deformans  of,  494 
diagnosis  of,  497 
etiology  of,  497 
pathology  of,  495 
contractures  of,  502 
diagnosis  of,  504 
paralytic,  510 
symptoms  of,  504 
treatment  of,  505 
coxitis  from  acute  osteomyelitis,. 
458 
course  of,  461 
diagnosis  of,  462 
pathology  of,  458 
prognosis  of,  462 
symptoms  of,  460 
treatment  of,  463 
by  direct  infection,  456 

diagnosis  of,  456 
symptoms  of,  456 
treatment  of,  456 
following     infectious     dis- 
eases, 453 
gonorrhceal,  454 
in  infancy,  455 
rheumatism  of,  acute  artic- 
ular, 455 
syphilitic,  455 
traumatic,  453 
typhoid,  455 
deformities  of,  paralytic,  510 
dislocation  of,  paralytic,  510 
hysterical,  501 
inflammation  at,  452 
loose,  510 

neuropathic  affections  of,  501 
resection  of,  524 
of  syringomyelia,  501 
of  tabes,  501 
tuberculosis  of,  463 
diagnosis  of,  475 

differential,  479 
prognosis  of,  483 
pathological    anatomy    of,. 
463 


906 


INDEX. 


Joints,  hip-,  tuberculosis  of,  symptoms  of, 
471 
treatment  of,  485 
wounds  of,  gunshot,  450 
diagnosis  of,  451 
prognosis  of,  451 
treatment  of,  451 
mediotarsal,  amputation  in,  877 
metacarpophalangeal,    tuberculosis 
of,  356 
prognosis  of,  350 
symptoms  of.  356 
treatment  of,  356 
metatarsal,  dislocation  in,  765 
metatarsophalangeal,     resection    of, 

887 
shoulder-,  ankylosis  of,  89 
treatment  of,  99 
contracture  of,  89 
contusions  of,  46 
diseases  of,  89 
hysterical,   102 
loose,  100 
neuroses  of,  102 
resection  of,  106 
sprains  of,  44 
wounds  of,  46 
of  tarsus,  suppuration  of,  783 

treatment  of,  783 
tibiotarsal,  acute  inflammations  of, 
781 
treatment  of,  782 
resection  of,  880 
of  toes,  acute  inflammations  of,  783 
treatment  of,  784 
resection  of,  887 
wrist-,  tuberculosis  of,  351 
diagnosis  of,  352 
symptoms  of,  351 
treatment  of,  352 


KNEE,  amputation  at,  713 
bursa?  of,  diseases  of,  649 
contusion  of,  565 
diagnosis  of,  566 
prognosis  of,  566 
treatment  of,  567 
deformities  of,  paralytic,  633 

static,  634 
diseases   of,    594.      See    also    Knee- 
joint, 
dislocations  of,  582 
backward,  583 

symptoms  of,  584 
treatment  of,  584 
forward,  583 

congenital,   587 

treatment  of,  587 
symptoms  of,  583 
treatment  of,  583 
menisci  of,  591 

symptoms  of,  592 
treatment  of,  592 
sideways,  584 

complications  of,  585 


Knee,  dislocations  of,  sideways,  diagnosis 
of.  585 
symptoms  of,  584 
treatment  of,  586 
habitual  subluxation  of,  587 
hsemarthrosis  of,  566 
injuries  of,  565 
-joint,  ankylosis  of,  626 

prognosis  of,  627 
treatment  of,  627 
contracture  of,  626 
prognosis  of,  627 
treatment  of,  627 

by  Braatz'  sector  splint, 
'629 

by    Hessing's    appara- 
tus. 629 
by  Schede's  extension, 
'628 
deformities  of,  paralytic,  633 

static,  634 
free  bodies  in,  621 

diagnosis  of,  623 
symptoms  of,  623 
treatment  of,  623 
haemophilia  in,  615 
prognosis  of,  616 
treatment  of,  616 
inflammations  of,  acute  exuda- 
tive, 594 
chronic  deforming,  619 

symptoms  of,  620 
treatment  of,  620 
intermittent  hydrops  of,  599 
neoplasms  of,  648 
neuralgia  of,  624 
neuropathic  affections  of,  624 
neurosis  of,  624 
rheumatism  of,  chronic,  618 
symptoms  of,  618 
treatment  of,  619 
synovitis  of,  594 

acute  purulent,  594 
seropurulent,   594 
serous,  594 
chronic,  599 
course  of,  597 
symptoms  of,  595 
treatment  of,  597 
syphilis  of,  617 

treatment  of,  618 
of  syringomyelia,  625 
of  tabes,  625 
tuberculosis  of,  600 
cause  of,  607 

pathological  anatomy,  600 
symptoms  of,  604 
treatment  of,  609 

by  arthrectomy,  613 
by    Bier's    congestion, 

'612 
bv    continuous   exten- 
sion, 600 
by  immobilization,  609 
by  iodoform  injection, 
'611 


INDEX. 


907 


Knee-joint,    tuberculosis   of,   treatment     I 
of,  by  partial  opera- 
tions, 612 
bv    portable     plaster- 
'  splint,  609 
by  n-scct ion.  014 
tumors  of,  6  Is 

Valleix's  pressure  points  in,  624 
wounds  of,  568 
gunshot,  569 
menisci  of,  dislocation  of,  591 
symptoms  of,  592 
treat menl  of,  592 
neoplasms  of,  646 
snapping,  633 

prognosis  of,  634 
treatment  of,  635 
sprains  of,  565 

diagnosis  of,  566 
prognosis  of,  566 
treatment  of,  567 
tumors  of,  646 
Knock-knees,  634 

Koeher's  amputation  of  shoulder,  l<n» 
coxa  vara,  513  . 

method   for   forward   dislocation   ot 

shoulder,  66 
resection  of  ankle-joint,  883 
subcortical    resection    of    shoulder- 
joint,  106 
Kolliker's  splint  for  club-foot,  814 
Konig's  method  for  club-foot,  817 
plates  for  dislocated  clavicle,  39 
resection  of  ankle-joint,  882 
splint  for  club-foot,  813 
Kramer's  incision  for  thrombosed  veins, 
694 

LACERATIONS  of    tendons    of    foot, 
730 

treatment  of,  730 
Landerer's  pad  for  varicose  veins,  693 
Langenbeck's    amputation    of    shoulder, 
109 
resection  of  ankle-joint,  880 
of  shoulder-joint,  106 
Lang's  treatment  of  inguinal  adenitis,  522 
Leg,  amputation  of,  713 
aneurism  in,  689 

symptoms  of.  689 
treatment  of,  689 
arteries  of.  ligation  of.  715 
bones  of,  shaft  of,  fractures  of,  671 
syphilis  of,  705 
tuberculosis  of,  703 

treatment  of.  705 
tumors  of.  710 
cellulitis  of,  684 
diseases  of,  684 
eczema  of,  684 
elephantiasis  of,  695 
prognosis  of.  696 
treatment  of.  i^Mi 
erysipelas  of,  684 
fractures  of,  671 


,eg,  Fractures  of,  intrauterine,   670 
furuncle  of,  684 
injuries  of,  6,  1 
malformations  of.  669 
operat  ion-  on,  713 
osteomyelitis  of.  acute,  697 
symptoms  of,  697 
treatment   of,   700 
modern,  702 
v.    Mosetig's    method, 
702 
varieties  of,  697 
phlegmon  of,  68 1 
pseudoarthrosis  of,  682 
rhachitic  curvature-  of ,  706 

treatment   of.    708 
soft  parts  of,  neoplasms  of.  709 

tumors  of,  709 
ulcers  of,  684 

prognosis  of,  686 
treatment  of,  686 
varicose  veins  of,  690 

treatment  of,  693 

by   ligation   of   saphe- 
nous, 694 
bv      Trendelenburg's 
"method,  694 
Lennander's  operation  for  inguinal  glands 

560 
Leprosy  of  fingers,  effects  of.  33*3 
of  foot,  774 
of  hand,  effects  of,  337 
Ligamentum  patellae,  rupture _of,  581 
Ligation  of  arteries  of  leg.  715 
of  axillary  artery,  105 
of  brachial  artery,   156 
of  cubital  artery,  227 
of  femoral  artery,  559 

in    adductor    canal,     after 

Hunter,  560 
in  middle  third,  after  Bell, 

560 
in   Scarpa's   triangle,   after 
Larrey,  559 
of  radial  artery,  259  _ 
at  wrist,  375 
of  saphenous  vein,  Trendelenburg's, 

694 
of  subclavian  arterv,  22 

vein,  104 
of  ulnar  artery,  259 

at  wrist,  375 
of  vessels  of  thigh,  559 
Lipoma  of  femur,  556 
of  foot,  870 
of  hand.  368 

diagnosis  of,  36S 
treatment  of,  369 
Lisfranc's    amputation     through    tarso- 
metatarsal joints.  879 
Loose  elbow-joint,  apparatus  for,  225 
hip-joint,  510 
shoulder-joint,   100 

prognosis  of,   100 
symptoms  of,  100 
treatment  of,  101 


908 


IXDEX. 


Lorenz'  method  for  club-foot,  818 
Lupus  of  foot,  774 
Lymphangiectasis  of  thigh,  550 

treatment  of,  550 
Lymphangioma  of  thigh,  557 
Lymphatics  of  thigh,  diseases  of,  550 
Lymph  cysts  of  thigh,  557 
Lymphoma,  leukemic,  of  groin,  558 

tuberculous,  of  thigh,  557 
Lymphosarcoma  of  thigh,  557 


MADURA  foot,  774 
Malformations  of  ami,  upper,  117 
of  bones  of  forearm,  243 
of  elbow-joint,  163 
of  foot,  722 
of  hand,  270 
of  hip,  389 
of  leg,  669 
of  radius,  243 
of  ulna.  243 
Malgaigne's  amputation,  subastragaloid, 

876 
Malleoli,  fractures  of,  733 
diagnosis  of,  738 
mechanism  of,  733 
symptoms  of,  737 
treatment  of,  738 
Mai  perforant,  867 

Martin's  method  for  ulcers  of  leg,  686 
Matas'  arteriorrhaphv.  657 
Median  nerve,  injuries  of.  126.  237 
at  elbow,  237 
symptoms  of,   126 
treatment   of,   127 
plastic  operations  on,  240 
in   upper  arm,  exposure  of,  156 
Mediotarsal  joint,  amputation  in.  877 
Menisci  of  knee,  dislocation  of,  591 
symptoms  of.  592 
treatment  of.  592 
Mensel's  apparatus  for  club-foot,  815 
Metacarpals,  amputation  of,  377 
fracture  of,  306 

treatment  of,  307 
resection  of,  384 
sequestrotomy  of.  384 
tuberculosis  of.  354 
symptoms  of,  355 
treatment  of,  355 
Metacarpophalangeal  joint,   tuberculosis 
of,  356 
prognosis  of,  356 
symptoms  of,  356 
treatment  of,  356 
Metacarpus,  dislocation  of,  309 
Metatarsals.     See  also  Metatarsus, 
amputation  of,  879 
dislocation  of,   770 

treatment  of,  770 
fractures  of,  768 

prognosis  of.  769 
treatment  of,  769 
inflammations  of,  in  infectious  dis- 
eases, 784 


Metatarsal  joint,  dislocation  in,  765 
osteomyelitis  of,  784 
and  phalanges,  dislocations  of,  769 

fractures  of.  768 
resection  of,  887 
rheumatism  of,  articular,  784 
gonorrheal,  784 
Metatarsalgia.  857 
Metatarsus.     See  also  Metatarsals. 

bones  of,  inflammation  of,  acute,  783 

treatment  of,  784 
dislocations  of,  total.  769 
diagnosis  of,  770 
prognosis  of,  770 
treatment  of,  770 
injuries  of,  769 

complicated.  771 
joints  of,  inflammation  of,  acute,  783 

treatment  of,  784 
and  toes,  injuries  of,  768 
Metatarsophalangeal  joints,  resection  of, 

887 
Middeldorpf's  triangle,  130 
Moles  of  hand,  367 
Monobrachia,   117 
Morton's  neuralgia,  857 
Morvan's  symptom-complex,  869 
v.  Mosetig's  bone-filling  for  cavities,  702 
Mothe's  method  for  forward  dislocation 

of  shoulder,  68 
Multiple  fracture.     See  Fractures. 
Muscles  of  thigh,  diseases  of,  551 
hernia  of,  534 

treatment  of,  535 
injuries  of,  533 
rupture  of,  533 

treatment  of,  534 
tumors  of,  557 
of  upper  ami,  abscess  of,  144 
angioma  of.  144 
diseases  of,  144 
gumma  of,  144 
hernia  of,  119 
ossification  of,  144 
injuries  of,  118 
rupture  of,  119 
Musculospiral  nerve,  injuries  of,  124 
symptoms  of,  125 
treatment  of,  125 
paralysis  of,   primary,   133 
symptoms  of,    133 
treatment  of,  133 
secondary,  133 

prognosis  of,  134 
symptoms  of,  134 
treatment  of,  134 
in  upper  arm.  exposure  of,  156 
Myositis,  syphilitic,  of  upper  ami,  144 
Myxoma  of  femur,  556 


N.'EVUS  pigmentosus  of  hand,  367 
Xelaton's    splint   for  Colles'    frac- 
tures, 297 
Xtoplasms  of  axilla,  83 
of  clavicle,  85 


INDEX 


009 


Neoplasms  of  foot,  S70 
benign,  870 
malignant,  871 

ill   hand,  305 

of  knee,  646,  648 
of  Leg,  709 
of  scapula,  80 

in  shoulder,  soft    parts  of,  84 

of  skin  of  upper  arm,  1  1 1 
of  thigh,  555 

soft    parts  of,  557 
Nerves  at  elbow,  diseases  of,  2.3G 
injuries  of,  230 
-joint,  location  of,  227 
operations   on,   240 
of  forearm,  operations  on,  261 
median,  injuries  of,  126,  237 
plastic  operations  on,  240 
in  upper  arm,  exposure  of,  156 
museulospiral,  injuries  of,  124 
symptoms  of,  125 
treatment  of,  125 
paralysis  of,  primary,  133 
symptoms  of,  133 
treatment  of,  133 
secondary,  133 

prognosis  of,  134 
symptoms  of,  134 
treatment  of,  134 
in  upper  arm,  exposure  of,  156 
radial,  injuries  of,  236 
at  elbow,  236 
plastic  operations  on,  240 
of  shoulder,  injuries  of,  23 
diagnosis  of,  24 
prognosis  of,  25 
symptoms  of,  24 
treatment  of,  25 
of  thigh,  diseases  of,  551 
stretching  of,  561 
tumors  of,  558 
ulnar,  injuries  of,  238 

plastic  operations  on,  239 
in  upper  arm,  diseases  of,  145 
exposure  of,  156 
injuries  of,  122 

course  of,    122 
prognosis  of,  122 
symptoms  of,  122 
treatment  of,  123 
neuroma  of,   145 

diagnosis  of,  146 
prognosis  of,  146 
treatment  of,  146 
Neuralgia  of  hip-joint,  501 
of  knee-joint,  624 
Morton's,  857 
of  venesection,  124 
Neuritis,  brachial,  145 

post-traumatic,  of  fingers,  318 
of  hand,  318 
Neuroma  of  hand,  370 

of  nerves  of  upper  arm,  145 

diagnosis  of,  146 
prognosis  of,  140 
treatment  of,   140 


Neuropathic  affections  of  foot,  867 
of  hip-joint,  5()l 

of  knee-joint ,  02  I 
arthritis  of  hand,  350 
omarthritis,  96 

diagnosis  of,  98 

pathology  of,  96 

prognosis  of,  98 

symptoms  of,  !J7 
Neurosis  of  knee-joint,  021 
of  shoulder- joint ,  102 

treatment   of,    103 


OBLIQl'E  fracture.     See  Fractures. 
(Edema,  malignant,  of  arm,   1  13 
Oettingen's  method  for  club-loot,  816 
Olecranon  bursitis,   144 
Ollier's  posterior  tarseetomy,  886 
resection  of  ankle-joint,  882 
of  shoulder-joint.  100 
Omarthritis,  89 
deformans,  95 

pathology  of,  95 
prognosis  of,  96 
symptoms  of,  96 
treatment  of,  96 
fibrous,  89 

symptoms  of,  90 
treatment  of,  90 
neuropathic,  96 

diagnosis  of,  98 
pathology  of,  96 
prognosis  of,  98 
symptoms  of,  97 
purulent,  91 

prognosis  of,  91 
symptoms  of,  91 
treatment  of,  91 
serous,  89 

symptoms  of,  90 
treatment  of,  90 
tuberculous,  92 

pathology  of,  92 
prognosis  of,  94 
treatment  of,  94 
Onychia,   770 

treatment  of,  770 
Onychogrvphosis.  775 
treatment  of,  770 
<  >nyxis,    776 

Operations  on  arm,  upper,  156 
on  elbow  and  forearm,  259 

-joint,  222 
on  fingers,  374 
on  foot  and  its  joints,  873 
on  forearm,  nerves  of,  261 
on  hand,  374 

plastic,  of  tendons,  375 
at  hip,  524 
on  leg,  713 
on  shoulder,  104 
on  thigh,  559 
on  wrist,  374 
Os  calcis.     See  Calcaneum. 
Ossification  of  biceps  tendon,  242 


910 


INDEX. 


Ossification  of  muscles  of  upper  arm,  144 
Osteoid  tumors  of  femur,  556 
Osteoma  of  foot,  870 

of  hand,  372 
Osteomyelitis  of  bones  of  forearm,  255 
symptoms  of,  255 
treatment  of,  256 
of  femur,  acute,  551 

symptoms  of,  552 
treatment  of,  554 
of  hip-joint,  acute,  458 
course  of,  461 
diagnosis  of,  462 
pathology  of,  458 
prognosis  of,  462 
symptoms  of,  460 
treatment  of,  463 
of  humerus,   147 
of  leg,  acute,  697 

symptoms  of,  697 
treatment  of,  700 
modern,  702 
by  v.  Mosetig's  method, 

. 702 
varieties  of,   697 

of  metatarsals,  784 

of  radius,  255 

symptoms  of,  255 

treatment  of,  256 

of  tibia,  acute,  697 

symptoms  of,  697 

treatment  of,  700 

of  toes,   784 

of  ulna,  255 

symptoms  of,  255 

treatment  of,  256 

Osteosarcoma  of  foot,  871 


PANARITIUM,  articular,  324 
course  of,  325 
treatment  of,  326 
cutaneous,  322 
osseous,  324 
parungual,  323 
subungual,  323 
of  tendon  sheaths,  323 
Papilloma  in  foot,  871 
Paralysis  of  forearm,  tendon  transplanta- 
tion for,  240 
pressure,  of  nerves  of  arm,  124 
primary,  of  musculospiral  nerve,  133 
secondary,   of   musculospiral  nerve, 
133 
Paralytic  contracture  of  hip-joint,  510 
deformities  of  hip-joint,  510 
symptoms  of,  511 
treatment  of,  511 
of  knee-joint,  633 
dislocation  of  hip-joint,  510 
loose  hip-joint,  510 
Paronychia,  776 

treatment  of,  776 
Patella,  dislocation  of,  congenital,  589 
treatment  of,  590 
downward,  591 


Patella,  dislocation  of,  lateral,  588 
prognosis  of,  589 
treatment  of,  589 
vertical,  590 

symptoms  of,  590 
treatment  of,  591 
fracture  of,  573 
cause,  575 
compound,  579 

treatment  of,  579 
prognosis  of,  575 
symptoms  of,  575 
treatment  of,  576 
ambulant,  576 

of  Kraske,  576 
of  zum  Busch,  576 
by  bandaging,  576 
Bardenheuer's      extension, 

576 
Malgaigne's  clamp,  576 
by  massage,  576 
open  suture,  578 

of    Dieffenbach, 

578 
of  Lister,  578 
of    Rhea    Barton, 

578 
of  Severino,   578 
subcutaneous  suture,  577 
of  Barker,  577 
of  Butcher,  577 
of  Ceci,   577 
of  Heusner,   577 
of  Kocher,  577 
of    v.    Volkmann, 
577 
Trelat's  method,  576 
refracture  of,  581 

treatment  of,  581 
rider-pain  of,  565 
Periarthritis  humeroscapularis,  78 
Periostitis,  post-traumatic,  of  fingers,  320 

of  hand,  320 
Perobrachia,  117 
Perrin's  incision,  877 
Pes.     See  Talipes. 

Phalanges  of  fingers,  amputation  of,  379 
dislocation  of,  309 

treatment  of,  310 
fracture  of,  308 

diagnosis  of,  308 
treatment  of,  308 
resection  of,  384 
sequestrotomy  of,  384 
of  foot,  fractures  of,  768 
prognosis  of,  769 
treatment  of,  769 
of  toes,  dislocations  of,  770 
Phlebitis  of  fingers,  331 

of  hand,  331 
Phlegmon  of  foot,  773 

of  leg,   684 
Phlegmonous  processes  in  arm,  143 

in  hand,  321 
Phocomelia,   117 
Pirogoff's  amputation  at  ankle,  873 


INDEX. 


911 


Plastic  operation  on  median  nerve,  240 
on  radial  nerve,  240 
on  ulnar  nerve,  239 
Polydactylia,  272 
Popliteal  aneurism,  654 

symptoms  of,  (555 
treatment  of,  655 

by  extirpation.  05(5 
by  ligation,  656 

and  excision,  656 
by  Matas'  artenorrhaphy, 
'  (i5  7 
bursa,  hygroma  of,  G52 
cysts,  052 

diagnosis  of,  653 
prognosis  of,  653 
treatment  of,  653 
space,  abscess  of,  654 

treatment  of,  654 
aneurism  in,  654 

symptoms  of,  655 
treatment  of,  655 
vessels,  injuries  of,  570 

treatment  of,  571 
Post-traumatic  neuritis  of  fingers,  318 
of  hand,  318 
periostitis  of  fingers,  320 
of  hand,  320 
Pott's  fracture,  733 
Prepatellar  bursitis,  acute,  650 
treatment  of,  650 
chronic,  650 

symptoms  of,  651 
treatment  of,  651 
tuberculous,  651 
Presenile  gangrene  of  fingers,  338 

of  hand,  338 
Pretibial  bursitis,  651 
Prothesis  for  upper  arm,  159 
Pseudarthrosis  of  humerus,  134 

anatomical  findings  of,  135 
diagnosis  of,  135 
etiology  of,  134 
prognosis  of,  135 
treatment  of,  135 
of  leg,   682 
Pseudoerysipelas  of  hand,  330 
prognosis  of,  331 
symptoms  of,  330 
Purulent  omarthritis,  91 
prognosis  of,  91 
symptoms  of,  91 
treatment  of,  91 


Q 


UADRICEPS     tendon,    rupture    of, 
581 


RADIAL  artery,  ligation  of,  259 
at  wrist,  375 
nerve,  injuries  of,  236 
at  elbow,  236 
plastic  operations  on,  91 
Radius,  defect  of,  243 
diseases  of,  255 


Radius,  dislocation  of,  congenital,  164 

head  of,  207 
lower  end  of,  303 
fracture  of,  Mead  of,  194 
etiology  of,  194 
symptoms  of,  194 
treatment  of,  194 
lower  end  of,  286 

after-treatment  of,  299 
anatomical  findings  of, 

289 
diagnosis  of,  293 
mechanism  of,  287 
prognosis  of,  299 
symptoms  of,  292 
treatment  of,  295 
neck  of,  195 

diagnosis  of,  195 
symptoms  of,  195 
treatment  of,  195 
shaft  of,  253 

diagnosis  of,  254 
etiology  of,  254 
treatment  of,  254 
malformations  of,  243 
osteomyelitis  of,  255 
symptoms  of,  255 
treatment  of,  256 
sarcoma  of,  257 
subluxation  of  head  of,  195 
tumors  of,  257 

and  ulna,  shaft  of,  fracture  of,  247 
prognosis  of,  248 
symptoms  of,  247 
treatment  of,  249 
Raynaud's  gangrene  of  foot,  865 
Refracture  of  patella,  581 
treatment  of,  581 
Resection  of  astragalus,  885 
of  calcaneum,  884 

Rigaud's  method,  884 
Olfier's  method,  885 
of  carpus,  380 
of  clavicle,   110 
of  elbow-joint,  222 
of  hip-joint,  524 

Bardenheuer's,  526 
Huter's,  525 
Konig's,  524 
Langenbeck's,  524 
Liicke's,  525 
Roser's,  525 
Schede's,  525 
Schmidt's,  526 
Sprengel's,  525 
Tiling's,  524 
of  humerus,   157 
of  joints  of  toes,  887 
of  metacarpals,  384 
of  metatarsals,  887 
of  phalanges  of  fingers,  384 
of  scapula,   111 
of  shaft  of  upper  arm,  157 
of  shoulder-joint,  106 
tibiocalcaneal,  of  v.  Bruns,  886 
of  tibiotarsal  joint,  880 


912 


INDEX. 


Resection  of  tibiotarsal  joint,  Kocher'>, 
884 
Konig's,  882 
Langenbeck's,  880 
Oilier' s,  883 
_  Vogt's,  883 
Wladimiroff  -  Mikulicz'  osteoplastic, 

886 
of  wrist-joint,  379 
Rhachitic  coxa  vara,  518 
curvatures  of  leg,  706 

treatment  of,  708 
of  thigh,  530 

treatment  of,  530 
Rheumatic  coxitis,  455 
Rheumatism,    articular,   of   metatarsals, 
784 
of  toes,  784 
chronic,  of  foot,  784 
of  knee-joint,  618 

symptoms  of,  618 
treatment  of,  619 
gonorrhreal,  of  metatarsals,  784 
of  toes,   784 
Rice  body  hygroma  of  subdeltoid  bursa, 

79 
Riders'  bone,  550 

treatment  of,  551 
pain  of  patella,  565 
Riedel's  method  for  forward  dislocation 

of  shoulder,  68 
Roloff's  method  for  forward  dislocation 

of  shoulder,   69 
Roser's  splint  for  Colles'  fracture,  297 
Rupture  of  biceps,  119 
of  deltoid,  19 

of  ligamentum  patellae,  581 
of  muscles  of  thigh,  533 

treatment  of,  534 
of  upper  arm,  119 

diagnosis  of,  120 
etiology  of,  119 
prognosis  of,  120 
symptoms  of,  120 
treatment  of,   120 
of  quadriceps  tendon,  581 


SAMPSON'S  toepost,  854 
Saphenous  vein,  ligation  of,  694 
Sarcoma  of  femur,  556 

treatment  of,  557 
of  foot,  871 

subungual,  871 
of  hand,  372 
of  humerus,   151 

diagnosis  of,  153 
prognosis  of,  153 
of  radius,  257 
of  ulna,  257 
Sayre's  splint,  31 

Scapula,  congenital  elevation  of,  17 
diseases  of,  86 
fractures  of,  41 

acromion  and  spine,  44 
prognosis  of,  4o 


Scapula,  fractures  of,  acromion  and  spine, 
symptoms  of,  44 
treatment  of,  45 
angles  of,  42 
body  of,  42 

diagnosis  of,  42 
prognosis  of,  42 
symptoms  of,  42 
treatment  of,  42 
eoracoid  process  of,  45 
etiology  of,  45 
symptoms  of,  45 
treatment  of,  45 
glenoid  portion  of,  43 
gunshot,  45 
surgical  neck  of,  43 

prognosis  of,  44 
symptoms  of,  44 
treatment  of,  44 
neoplasms  of,  80 
resection  of,   111 
tumors  of,  86 
Scarpa's  splint   for  club-foot,  815 
Schede's  splint  for  Colles'  fracture,  298 
Schinzinger's    method    for   forward   dis- 
location of  shoulder,  66 
Schiissler's  apparatus  for  loose-shoulder, 

601 
Sciatic  nerve,  open  stretching  of,  561 
Sciatica  of  thigh,  551 

treatment  of,  551 
Scudder's  dressing  for  fractured  clavicle, 
30 
humerus,  57 
Sebaceous  cyst  of  hand,  309 
Senile  gangrene  of  fingers,  338 

of  hand,  338 
Sensory  disturbances  of  foot,  869 

treatment  of,  870 
Sequestrotomy  of  metacarpals,  3S4 

of  phalanges,  384 
Sharp's  amputation  through  metatarsals, 

879 
Shoe,  correct  shape  of,  842 
for  flat-foot,  842 
of  Beelv,  843 

of  Miller  and  Thomas,  843 
plate  of  Hoffa,  843 
of  Whitman,  844 
Shoulder,  amputation  at,  108 

intrascapulothoracic,  112 
bursa?  of,  diseases  of,  78 
congenital  elevation  of,  17 
dislocations  of,  60 
backward,  71 

infraspinate,  71 

diagnosis  of,  72 
prognosis  of,  72 
symptoms  of,  71 
subacromial,  72 
congenital,  18 

deltoid  paralysis  following,  70 
forward,  61 

axillary,  61 

anatomical  findings  of, 
62 


INDEX. 


913 


Shoulder,  dislocations   of,    forward,    axil- 
lary, diagnosis  of,  •'.  I 
prognosis  of,  65 
symptoms  of,  64 
treat  menl  of,  65 
subcoracoid,  61 
habitual,  7<> 

treatment  of,  77 
old,  73 

anatomy  of,  73 
prognosis  of,  71 
symptoms  of,  7 1 
treatment  of,  75 
-joint,  ankylosis  of,  89 

treatment  of,  99 
contracture  of,  99 

treatment  of,  99 
contusions  of,  44 
diseases  of,  89 
hysterical,  102 
loose,   100 
neuroses  of,  102 
resection  of,  106 
sprains  of,  44 
tuberculosis  of,  92 
wounds  of,  46 

prognosis  of,  48 
treatment  of,  48 
muscles  of,  injuries  of,  19 
nerves  of,  injuries  of,  23 
diagnosis  of,  24 
prognosis  of,  25 
symptoms  of,  24 
treatment  of,  25 
operations  on,   104 
skin  of,  injuries  of,  19 
soft  parts  of,  neoplasms  of,  84 
tumors  of,  84 
vessels  of,  injuries  of,  20 
prognosis  of,  22 
treatment  of,  22 
Skin  at  elbow,  diseases  of,  229 
of  shoulder,  injuries  of,  19 
of  thigh,  tumors  of,  557 
of  upper  arm,  neoplasms  of,  144 
tumors  of,  144 
Snapping  finger,  363 
knee,  633 

prognosis  of,  634 
treatment  of,  634 
Spina  ventosa,  of  fingers,  353 
Spinal  fracture.     See  P'ractures. 
Splint,  v.  Brims',  for  leg  and  thigh,  541 
Buck's  extension,  545 
extension  for  femur,  540 
Helferich's  extension  for  femur,  541 
Hessing's,  for  thigh,  542 
Hodgen's  suspension,  545 
Schede's  suspension  for  thigh,  542 
v.  Yolkmann's,  540 
Splinter  fracture.     See  Fractures. 
Sprains  of  ankle-joint,  728 
treatment  of,  728 
of  elbow-joint,  166 
diagnosis  of    167 
prognosis  of,  167 
Vol.  III.— 58 


Sprains  of  elbow-joint,  treatment  of,  1  <)7 
Of  knee,  505 

diagnosis  of,  566 

prognosis  of,  566 
treatmenl  of,  567 

of  shoulder-joint .    1  I 
of  wrist ,  27!» 

diagnosis  of,  280 
treatment    of,   280 
Sprengel's  deformity,    17 
Static   deformities  of   knee,   634 

Stimson's  fenestrated  splint  lor  leg,  079 
method  for  dislocated  clavicle,  39 
for  forward  dislocation  of  shoul- 
der, 68 
splint  for  Colles'  fracture,  299 

for  fractures  of  humerus,  174 
for  Pot  fc's  fracture,  7  10 
Storp's  suspension   cuff,   298 
Stretching  of  nerves  of  thigh,  561 
Subastragaloid  amputation,  876 
dislocation,  758 

backward,  760 
forward,  760 
inward,  758 
onward,  7(50 
outward,  759 
Subclavian  artery,  injuries  of,  20 
ligation  of,  22 
vein,  ligation  of,   104 
Subcoracoid  dislocations  of  shoulder,  61 
Subdeltoid  bursitis,  78 

tuberculous,   79 
Subiliac  bursitis,  521 
Subluxation  of  head  of  radius,  195 

of  knee,  habitual,  587 
Subungual  growths  in  foot,  870 
Supernumerary-  digits,  272 

toes,  722' 
Suppuration  of  bones  of  tarsus,  783 
treatment  of,  783 
of  elbow-joint,  211 
of  joints  of  tarsus,  783 

treatment  of,  783 
of  tendon  sheaths  of  fingers,  323 
Suppurative    inflammation    of    inguinal 

glands,  522 
Supracondyloid  fracture  of  humerus,  169 
diagnosis  of,  172 
etiology  of,  169 
mechanism  of,   169 
prognosis  of,  176 
symptoms  of,  171 
treatment  of,  172 
Supramalleolar  fractures,  731 
diagnosis  of,  732 
prognosis  of,  733 
treatment  of,  733 
Syme's  amputation  at  ankle,  873 
Synovial  sacs  at  elbow,  diseases  of,  233 

injuries  of,   233 
Synovitis  of  ankle-joint,  acute,  781 
gonorrhceal,  782 
hemorrhagic,  782 
in   infectious  diseases,   782 
serous,  781 


914 


INDEX. 


Synovitis    of    ankle-joint,    suppurative, 
782 
treatment  of,  782 
of  knee-joint,  594 

acute  purulent,  594 
seropurulent,  594 
serous,  594 
chronic,  599 
course  of,  597 
symptoms  of,  595 
treatment  of,  597 
Syphilis  of  bones  of  leg,  705 
of  clavicle,  85 
of  elbow-joint,  211 
of  fingers,  329 
of  foot,   774 
of  hand,  331 

hereditary,  349 
primary  effects  of,  329 

treatment  of,  330 
of  humerus,   149 
of  knee-joint,  617 

treatment  of,  618 
of  tibia,  705 
Syphilitic  affections  of  fingers,  336 
of  hand,  336 
of  skeletal  foot,  785 
coxitis,  455 
cubital  adenitis,  143 
inflammation  of  inguinal  glands,  522 
myositis  of  upper  arm,  144 
tenosynovitis  of  fingers,  345 
of  hand,  345 
Syringomyelia  in  fingers,  effects  of,  337 
in  hand,  effects  of,  337 
of  knee-joint,  625 
Szymanowski's  towel  dressing,  30 


TABETIC  diseases  of   ankle-joint,  869 
hip-joint,  501 
knee-joint,  625 
of  tarsus,  869 
Talipes  calcaneus,  846 

sensu  strictiori,  846 
sensuni  plexus,  846 
treatment  of,  848 
cavus,  850 
equinus,  824 

pathological  anatomy  of,  826 
symptoms  of,  826 
treatment' of,  827 
valgus,  829 
varus,  800 
Tarsal  bones,  dislocations  of,  758 
small,  fractures  of,  750 

treatment  of,  751 
Tarsectomy,  anterior,  886 

for  club-foot,  methods  of,  821 
posterior,  885 
Tarsus,  bones  of,  suppuration  of,  783 
treatment  of,  783 
fractures  of,  744 
joints  of,  suppuration  of,  783 

treatment  of,  783 
tabetic  disease  of,  869 


Tear-fracture  of  spine  of  tibia,  582 
Telangiectasis  of  foot,  870 

of  hand,  367 
Tendo  Achillis,  subcutaneous  division  of, 

821 
Tendons  of  elbow,  diseases  of,  233 
injuries  of,  233 
of  foot,  dislocations  of,  729 
treatment  of,  730 
injuries  of,  729 
lacerations  of,  730 

treatment  of,  730 

transplantation  of,  798 

of  forearm,  diseases  of,  233 

injuries  of,  233 
of  hand,  dislocations  of,  280 
open  division  of,  282 
operations  on,  283,  375 
subcutaneous  laceration  of,  281 
suture  of,  283 
sheath  at  elbow,  diseases  of,  233 

injuries  of,  233 
sheaths  of  fingers,  blood  extravasa- 
tion in,  342 
diseases  of,  342 
gonorrhoea  of,  343 
panaritium  of,  323 
suppuration  of,  323 
syphilis  of,  343 
tenosynovitis  of,  acute  ser- 
ous, 342 
tuberculosis  of,  343 
of  foot,  diseases  of,  778 

treatment  of,  780 
of  hand,  265 

blood  extravasation,  342 
diseases  of,  342 
gonorrhoea  of,  343 
syphilis  of,  343 
tenosynovitis  of,  acute  ser- 
ous, 342 
tuberculosis  of,  343 
transplantation  in  foot,  798 

for  paralysis  of  forearm,  240 
for  talipes  calcaneus,  849 
at  wrist,  375 
Tenosynovitis  of  fingers,  343 
gonorrhceal,  343,  345 
syphilitic,  345 
tuberculous,  343 
of  hand,  343 

gonorrhceal,  343,  345 
syphilitic,  345 
tuberculous,  343 
Textor's  amputation,  877 
T-fractures  of  condyles  of  humerus,  177 
diagnosis  of,  178 
etiology  of,  177 
mechanism  of,  177 
symptoms  of,  178 
treatment  of,  178 
Thigh,  amputation  of,  562 
Abrashanow's,  564 
Buchanan's,  563 
Cardan's,  563 
Djelitzyn's,  563 


i\di:x 


915 


Thigh,  amputation  of,  Farabeuf's,  562 
Gritti's,  562 
Jacobson's,  564 
Spencer's,  562 
Ssabanejeff's,  -~»« "•;> 
aneurism  of,  5  19 

treatment  of,  5l'.i 
bone  of,  diseases  of,  551 
injuries  of,  535 
tumors  of,  555 
carcinoma  of,  557 
chondrofibroma  of,  cystic,  555 
chondroma  of,  556 
curvatures  of,  530 
rhachitic,  530 

treatment  of,  530 
deformities  of,  530 

due  to  epiphyseal  maldevelop- 

ment,  530 
lower  end  of,  530 

treatment   of,   531 
phocomelia,  530 

treatment  of,  530 
rhachitie,  530 

treatment  of,  530 
diseases  of,  549 
echinoeoceus  of,  557 
enehondroma  of,  555 
fibroma  of,  556 
Hoffmann's  prothesis  for,  564 
inflammatory  processes  of,  551 
lipoma  of,  556 
lymphangiectasis  of,  550 

treatment  of,  550 
lymphatics  of,  diseases  of,  550 
muscles  of,  diseases  of,  550 
hernia  of,  534 

treatment  of,  535 
injuries  of,  533 
rupture  of,  533 

treatment   of,  534 
tumors  of,  557 
myxoma  of,  556 
neoplasms  of,  555 
nerves  of,  diseases  of,  551 
stretching  of,  561 
tumors  of,  558 
operations  of,  559 
osteomyelitis  of,  acute,  551 
symptoms  of,  .552 
treatment  of,  554 
riders'  bone  of,  550 

treatment  of,  551 
sarcoma  of,  556 

treatment  of,  557 
sciatica,  551 

treatment   of.  551 
skin  of,  tumors  of,  557 
soft  parts  of,  atheroma  of,  557 
carcinoma  of,  557 
dermoid  cysts  of,  557 
diseases  of,  549 
echinoeoceus  of,  557 
elephantiasis   nervorum   of 

(v.  Bruns),  558 
enehondroma  of,  557 


Thigh,    Bofl    parts    of,    fibrolipoma    of, 
557 
fibroma  of,  557 
hemangioma  of,  557 
bydroma  of,  557 
leukemic  lymphoma  of,558 
lipoma  of,  557 
lymph  cysts  of,  557 
lymphangioma  of,  557 
lymphosarcoma  of.  557 
myxoma  of,  557 
neoplasms  of,  557 
neurofibroma  of,  558 
osteoma   of,  7,7>~ 

sarcoma  of,  557 
tuberculous  lymphoma  of, 
557 

tumor-  of.  557 
transplantation  of  tendons  of,  561 
tumors  of.  555 
varicose  veins  of,  550 

treatment  of,  550 
vessels  of,  diseases  of,  549 
injuries  of,  532 
ligation  of,  559 
wounds  of,  gunshot,  546 
Thumb,  dislocation  of,  311 
mechanism  of,  311 
symptoms  of,  312 
treatment  of.  313 
Tibia,  fractures  of,  shaft  of,  671 
diagnosis  of,  674 
prognosis  of,  675 
treatment  of,  676 
tuberosities  of,  572 
treatment  of,  573 
osteomyelitis  of,  acute,  697 
symptoms  of,  697 
treatment  of,  700 
syphilis  of,  705 
tuberculosis  of,  703 
treatment  of,  705 
Tibial  spine,  tear-fracture  of,  582 
Tibiocalcaneal  resection  of  v.  Bruns,  886 
Tibiotarsal  joint,  inflammations  of,  acute, 
781 
treatment  of,  782 
resection  of,  880 
Toe-nails,  diseases  of,  775 
ingrowing,  776 

treatment  of,  777 
Toes,  amputation  of,  880 

bones  of,  inflammation  of,  acute,  783 

treatment  of,  784 
contractures  of,  851 
extension  of,  856 
flexion  of,  856 
lateral,  856 
deformities  of,  851 
inflammation   of,   in   infectious   dis- 
eases,  784 
injuries  of,  768 

complicated,  771 
joints  of,  inflammation  of,  acute,  783 

treatment  of,  784 
osteomyelitis  of,  784 


916 


INDEX. 


Toes,  phalanges  of,  dislocation  of,  770 
resection  of,  887 
rheumatism  of,  articular,  784 

gonorrhoeal,  784 
supernumerary,   722 
Torsion  fracture.     See  Fractures. 
Transplantation  of  tendons  at  thigh,  561 
Trapezius,  traumatic  lesions  of,  19 
Traumatic  coxitis,  453 
Trendelenburg's  operation   for    varicosi- 
ties,  694 
test  for  varicosities,  691 
Trigger  finger,  363 
Tripier's  amputation,  877 
Trochanteric  bursitis,  521 
deep,  521 
superficial,  521 
Trophic  disturbances  of  fingers,  337 
of  foot,  869 

treatment  of,  870 
of  hand,  337 
Tuberculosis  of  ankle,  skin  of,  774 
of  clavicle,  85 
of  elbow-joint,  215 
prognosis  of,  216 
symptoms  of,  215 
treatment  of,  217 
of  fibula,  703 

treatment  of,  705 
of  fingers,  354 
skin  of,  333 

symptoms  of,  355 
treatment  of,  355 
of  foot,  bones  of,  786 

diagnosis  of,  788 
frequency  of,  786 
symptoms  of,  787 
treatment  of,  790 
joints  of,  786 

diagnosis  of,  788 
frequency  of,  786 
symptoms  of,  787 
treatment  of,  790 
skin  of,  774 
of  hand,  bones  of,  351 

skin  of,  333 
of  hip-joint,  463 

diagnosis  of,  475 

differential,  479 
pathological  anatomy  of,  463 
prognosis  of,  483 
treatment  of,  485 
of  humerus,  shaft  of,  149 
of  knee-joint,  600 
course  of,  607 

pathological  anatomy  of,  600 
primary  osteal,  602 

synovial,  600 
symptoms  of,  604 
treatment  of,  609 

by  arthrectomy,   613 

by  Bier's  congestion,  612 

by    continuous    extension, 

'609 
by  immobilization,  609 
by  iodoform  injection,  611 


Tuberculosis    of    knee-joint,     treatment 
of,  by  partial  operations, 
612 
by  portable   plaster-splint, 

'609 
by  resection,  614 
of  metacarpals,  354 
symptoms  of,  355 
treatment  of,  355 
of  metacarpophalangeal  joint,  356 
prognosis  of,  356 
symptoms  of,  356 
treatment  of,  356 
of  shoulder-joint,  92 
of  subdeltoid  bursa,  79 
of  tibia,  703 

and  fibula,  703 
treatment  of,  705 
of  wrist-joint,  351 

diagnosis  of,  352 
symptoms  of,  351 
treatment  of,  352 
Tuberculous  adenitis  of  axilla,  80 
omarthritis,  92 

pathology  of,  92 
prognosis  of,  94 
treatment  of,  94 
tenosynovitis  of  fingers,  343 
of  hand,  343 
Tumors  of  axilla,  83 

of  bones  of  forearm,  257 

of  clavicle,  85 

of  foot,   870 

of  groin,   557 

of  hand,   365 

of  humerus,    149 

of  inguinal  glands,  557 

region,  557 
of  knee,  646 

-joint,  648 
of  leg,   709 
of  radius,  257 
of  scapula,  85 
in  shoulder,  84 
of  skin  of  upper  arm,  144 
of  thigh,  bone  of,  555 
muscles  of,  557 
nerves  of,  558 
skin  of,  557 
soft  parts  of,  557 
of  ulna,  257 


ULCERS  of  foot,  perforating,  867 
treatment  of,  868 
of  leg,  684 

prognosis  of,  686 
treatment  of,  686 

by  aluminum  acetate,  686 

ambulant,  687 

by     continuous     elevation, 

'688 
by  dusting  powders,  687 
by  excision  and  grafting,  688 
by     Hirschberg's    method, 
'688 


INDEX. 


917 


Ulcers  of  leg,  treatment  of,  by  Krause's 
method,  088 
by  Mariani's  method,  688 
by      Tuna's      zinc-gelatin 

dressing,   687 
Ulna,  defect  of,  243 
diseases  of,  255 
dislocation  of,  at  elbow,  207 

Lower  end  of,  303 
Eracture  of,  coronoid  process  of,  189 
prognosis  of,  L90 
symptoms  of,  190 
treatment  of,  190 
olecranon  process  of,  190 
prognosis  of,  192 
symptoms  of,  190 
treatment  of,  192 
shaft  of,  251 

etiology  of,  251 
prognosis  of,  253 
symptoms  of,  252 
treatment  of,  253 
malformations  of,  243 
osteomyelitis  of,  255 
symptoms  of,  255 
treatment  of,  256 
sarcoma  of,  257 
tumors  of,  257 
Ulnar  artery,  ligation  of,  259 
at  wrist,  375 
nerve,  diseases  of    145 
injuries  of,  122,  238 
course  of,  122 
at  elbow,  238 
prognosis  of,  122 
symptoms  of,  122 
treatment  of,  123 
neuroma  of,  145 

diagnosis  of,  146 

prognosis  of,  146 

treatment  of,  146 

plastic  operations  on,  233 

in  upper  arm,  exposure  of,  156 

Unna's  zinc-gelatin  for  ulcers  of  leg,  6S7 

VARICOSE  veins  of  leg,  690 
treatment  of,  693 

by   ligation   of   saphe- 
nous,  694 
by    Trendelenburg's 
method,  694 
of  thigh,  550 

treatment  of,  550 
Vein,  femoral,  injuries  of,  532 
saphenous,  ligation  of,  694 
subclavian,  ligation  of,  104 
Veins,  varicose,  of  leg,  690 

treatment  of,  693 

by  ligation  of  saphe- 
nous,  694 
by      Trendelenburg's 
method,  694 
of  thigh,  550 

treatment  of,  550 
Velpeau  dressing,  29 


Venesection,  neuralgia  of,  121 
Vessels  of  arm,  upper,  injuries  of,  121 

diagnosis  of,   121 
prognosis  ol ,   121 
subcutaneous,  121 
treatment    of,   121 
<>f  elbow,  diseases  of,  231 

injuries  of,  23  1 

and  forearm,  diseases  of,  234 

injuries  of,   234 
popliteal,  injuries  of,  520 

treat  inent  of,  577 
of  shoulder,  injuries  of,  20 
prognosis  of,  22 
treatment  of,  22 
of  thigh,  diseases  of,  549 
injuries  of,  532 
Vogt's  resection  of  ankle-joint,  883 
v.  Volkmann's  apparatus  for  talipes  cal- 
caneus, 849 
splint  for  leg,  677 
Vulpius'  aluminum  splint  for  arm,  131 
for  leg,  676 


WARTS  of  foot,  871 
of  hand,  367 

treatment  of,  367 
Welander's  treatment  of  inguinal  adenitis, 

523 
Whitman's  brace  for  metatarsalgia,  861 

shoe  brace,  844 
Wille's  bone  suture,  136 
Wing-skin,  229 

Witzel's  anterior  tarsectomy,  887 
Wladimiroff-Mikulicz'  osteoplastic  resec- 
tion, 886 
Wounds  of  arm,  upper,  severe,  lacerated, 
141 
of  elbow-joint,  gunshot,  197 
of  fingers,  314 

serious  results  of,  317 
of  hands,  314 
of  hip-joint,  gunshot,  450 
diagnosis  of,  451 
prognosis  of,  451 
treatment  of,  451 
of  knee,  568 

-joint,  568 
of  muscles  of  upper  arm,  11*8 
of  shoulder-joint,  46 

prognosis  of,  48 
treatment  of,  48 
of  thigh,  gunshot,  546 
Wrist,  contusions  of,  279 
diagnosis  of,  280 
treatment  of,  280 
dislocation  of,  301 

single  bones  of,  303 
treatment   of,  302 
ganglion  of,   365 

treatment   of,  366 
injuries  of,  complicated,  304 

treatment  of,  305 

-joint,  tuberculosis  of,  351 

diagnosis  of,  352 


918 


INDEX. 


Wrist-joint,  tuberculosis  of,  symptoms  of, 
351 
treatment  of,  352 
ligation  of  radial  artery  at,  375 

of  ulnar  artery  at,  375 
operations  on,  374 
sprains  of,  279 

diagnosis  of,  280 
treatment  of,  280 


Y -FRACTURE  of   condyles  of  hume- 
rus,  177 
diagnosis  of,  178 
etiology  of,   177 
symptoms  of,   178 
treatment   of,    178 


z 


INC-GELATIN,   Tuna's,  689 


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